Card Room Employee Upgrade Form

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Fillable Card Room Employee Upgrade Form Printable pdf

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WASHINGTON STATE GAMBLING COMMISSION

LOCATION: 4565 7th Avenue SE, Lacey WA 98503

PRINT

MAILING ADDRESS: P.O. Box 42400, Olympia WA 98504-2400

TELEPHONE: 360-486-3440 / FAX NUMBER: 360-486-3631

RESET FORM

TOLL-FREE: 1-800-345-2529 / TDD: 360-486-3637

WEB SITE:

CARD ROOM EMPLOYEE UPGRADE

TYPE OF APPLICATION

FEE: $

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See Section 4 (Transfer / Additional Employee / Conversion /

Upgrade:

Emergency Waiver Request) of the attached fee schedule.

From: Class E Card Room (65)

To: Class F Endorsed (65) and/or House-Banked (67) Card Room Employee.

You are required to submit a fingerprint card (attached FD-258), follow the instructions

(GC5-231

and GC5-232).

NOTE: All refunds of application / license fees will be issued to the applicant.

Applicant License #: 68-|___

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1. Name of

Applicant: |___

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Last Name

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First Name

MI

Social Security Number: |___

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Address: |___

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City

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Zip

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County

Telephone

2. Current or

Previous Employer:

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Name

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City

Telephone

3. New Employer:

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Name

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City

Telephone

4. First Day of Work: |___

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Expiration Date: |___

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ORG #: 00-|___

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Business Office Use Only:

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$|___

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________________________

Code: 211-

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Date:

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Amt:

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Val #:

GC4-160 (Rev. 10/15)

Our Mission: Protect the Public by Ensuring that Gambling is Legal and Honest

Page 1 of 2

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