Form 50c - Nebraska Application For Gaming Manager

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Nebraska Application for Gaming Manager

Form

50C

• License fee is $100.

• Incomplete applications will be returned.

1 Licensed Organization’s Name

Please Do Not Write in This Space

2 Nebraska ID Number of Licensed Organization

3 Type of Application

PRINT FORM

RESET FORM

New

Report Changes

Renewal

Cancel (Return license)

Gaming Manager Information (Attach additional sheet if necessary.)

Social Security Number

Name

Street Address

Date of Birth

PO Box

City

State

Zip Code

County

Your Social Security number and date of birth are required under the Nebraska Bingo Act, and will be used to request criminal history

information from law enforcement agencies to determine if the legal requirements for a gaming manager’s license are met.

4 Are you currently a bingo chairperson or alternate bingo chairperson, as indicated on the Nebraska Schedule I – Bingo License, Form 50, submitted by any licensed organization?

Yes

If Yes, indicate the licensed organization’s name and Nebraska ID Number:

Licensed Organization’s Name

Nebraska ID Number

5 Do you hold or have you previously held any other licenses issued under the Nebraska Bingo Act, the Nebraska Pickle Card Lottery Act, the Nebraska Lottery and Raffle Act, or

the Nebraska County and City Lottery Act?

Yes

If Yes, indicate the types of licenses and their current status (active, suspended, canceled, revoked, expired):

6 Do you or your spouse have any interest, directly or indirectly, in any business licensed as a commercial lessor of bingo premises or as a manufacturer or distributor of bingo

equipment and/or pickle card units in Nebraska?

Yes

If Yes, provide a detailed explanation:

7a Have you been convicted of, forfeited bond upon a charge of, or pled guilty or nolo contendere to any felony or misdemeanor at any time involving fraud, theft, any gambling

activity, willful failure to make required payments or reports, or filing false reports with a governmental agency at any level? This includes shoplifting or issuing bad checks.

Yes

7b Have you been convicted of, forfeited bond upon a charge of, or pled guilty or nolo contendere to any felony other than those listed in 7a within the last 10 years?

Yes

If you answered Yes to 7a or 7b, indicate the date and place the incident occurred, the court case or docket number under which it is filed, the original charge or ultimate

disposition of the matter, and a description of the events which are the subject of the incident.

8 Have you ever been fingerprinted for a license under the Nebraska Bingo Act, the Nebraska Pickle Card Lottery Act, or the Nebraska County and City Lottery Act?

Yes

Type of License:

If Yes, indicate the approximate date you were fingerprinted and the type of license involved.

Date:

9 Have you ever been fingerprinted by the Nebraska Liquor Control Commission in conjunction with an application for a liquor license?

Yes

Liquor License Number:

If Yes, indicate the approximate date you were fingerprinted and the number of the liquor license. Date:

If you answered No to lines 8 and 9, see the instructions for lines 8 and 9 on the reverse side of this application.

10 For New Applicants Only. For the purpose of complying with

Neb. Rev. Stat. §§ 4-108 through

4-114, I attest as follows:

I am a citizen of the United States; or

I am a qualified alien under the federal Immigration and Nationality Act. My immigration status and alien number are__________________________________, and I

agree to provide a copy of my USCIS documentation upon request.

11 Type of Compensation

Salary

per

Other, explain

Volunteer, no compensation

Under penalties of law, I declare that I have examined this application, and to the best of my knowledge and belief, it is correct and complete. I hereby attest

that my response and the information provided in Line 10 and any related application for public benefits are true, complete, and accurate. I understand that this

information may be used to verify my lawful presence in the United States. I will comply with all of the provisions of the Nebraska Bingo Act, the Nebraska Pickle

Card Lottery Act, the Nebraska Lottery and Raffle Act, the Nebraska Small Lottery and Raffle Act, and the regulations adopted under such Acts.

sign

(

)

here

Signature of Applicant

Date

Daytime Phone Number

Email Address

Licensed Organization Authorization — Signature of Utilization of Funds Member

I declare that I have examined this application and approve the person to act as a gaming manager on behalf of the above-named licensed organization.

sign