Fillable Card Room Employee Upgrade Form (Page 2 of 2) in pdf

5. Since your last application, have you been charged with a crime, paid a fine, been arrested, jailed, convicted, gone

through diversion or placed on probation?

 Yes

 No

If yes, please attach a statement of explanation.

OATH OF APPLICANT

I declare under penalty of perjury, under the laws of the State of Washington, that all information provided on this

application is true and complete to the best of my knowledge. I understand that untruthful, misleading, or incomplete

answers whether through misrepresentation, concealment, inadvertence, or mistake, are cause for denial of my

initial application or revocation of any gambling license(s) currently held. I understand that I must notify the

Gambling Commission if any information required on this application or on my Personal / Criminal History Statement

changes or becomes inaccurate in any way. I understand that I must also notify the Gambling Commission should any

criminal or civil actions be filed against me during the application or license period. (See WACs 230-03-055, 230-06-080,

230-06-085

and 230-06-090.) I understand that if I fail to make such notification it may be grounds for denial, suspension

or revocation of my application or license(s). [See

RCW 9.46.075(7)

and

WAC

230-03-085(7).] I understand that if I

voluntarily withdraw or if the Commission administratively closes my application, the remainder of my fee, minus

processing and investigative costs, will be refunded.

I understand that I am responsible to know and comply with all rules and laws,

RCW 9.46

and

WAC

230, which can be

found on the Internet websites of the

Washington State Gambling Commission

or the

Washington State

Legislature.

Signature: _____________________________________________________ Date: |___

___|/|___

___

___|

First, Middle, Last

EMPLOYER AUTHORIZATION

I hereby authorize the applicant to submit this application. The applicant has been accepted for employment. I will

provide training and ensure that this employee is provided with a copy of the training packet within the first thirty days of

employment.

Signature of Employer: _______________________________________________________________________________

First, Middle, Last

Print Name:

Last: |___

___

___|

First: |___

___

___|

MI: |___|

Title: |___

___

___|

WHO MAY USE THIS FORM:

ACTIVE

Only Licensed Public Card Room Employees with

licenses may use this form. If your license has

expired do not use this form, call the Agency.

Use this form to upgrade from Class E Card Room (65) to Class F Endorsed (65) and/or House-Banked (67) Card Room

Employee.

YOUR APPLICATION AND THE PUBLIC RECORDS ACT

From the moment we receive your application, it becomes a public document subject to the Public Records Act

(RCW

42.56) and other Washington laws. The Commission may disclose to the public, other state or federal agencies, or

discuss at a public meeting all information set forth in this application and all supplemental information submitted. The

Commission responds to public document requests through a Public Disclosure Request process. In the event that the

Commission receives a public disclosure request regarding this application or the license file established, you may

request in writing, that the Commission notify you of such request as provided in

RCW

42.56.540.

RESET FORM

GC4-160 (Rev. 10/15)

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

Page 2 of 2

Card Room Employee Upgrade Form Page 2

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