Renewal Application For Registration - Lottery Retail Contract Manager Or Designate Contract Manager Page 3
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4Renewal of Registration
Gaming Policy and Enforcement Branch
Lottery Retail Contract Manager or Designate Contract Manager
SECTION 5 – CONSENT AND CERTIFICATION
NOTE: Applicants must provide their signature in the space provided below to indicate they understand and agree to the following.
Consent to the Use and Disclosure of Personal Information
Background Checks and Disclosure of Personal Information
I hereby authorize:
Background checks will include but are not limited to credit history,
criminal record, Police Information and other indices checks including
1. The Gaming Policy and Enforcement Branch (GPEB) to investigate my
internet searches. The Canadian Police Information Centre (CPIC)
suitability, or continuing suitability, for Registration in the gaming industry
database records will be queried for the disposition of all charges for which
pursuant to Part 7 and 8 of the Gaming Control Act and Gaming Control
a person has been fingerprinted (Criminal Record) and all outstanding
Regulation. I understand that GPEB is required to protect the
charges currently before the courts. Police records will be queried through
confidentiality and privacy of personal information provided, in accordance
the Public Safety Portal (PSP) which accesses RCMP, City, Municipal,
with The Freedom of Information and Protection of Privacy Act (British
Provincial, Federal police databases and any other law enforcement
Columbia).
databases in Canada. These databases record all complaints the
respective police departments investigate and include information related
2. Any City, Municipal, or Provincial Police department, law enforcement
to non convictions and charges regardless of disposition. Checks will be
agency or public body including GPEB, pursuant to Section 33 of the
conducted through State, County, Sheriffs, FBI or other police databases
Freedom of Information and Protection of Privacy Act (British Columbia),
in the USA that are appropriate. Therefore full disclosure of all criminal
and the Royal Canadian Mounted Police pursuant to Section 8 (1) of the
and civil proceedings is required and each case will be decided on its own
Privacy Act of Canada, to release any and all personal information and
merit. If necessary, an applicant will be required to provide fingerprints to
records, (including convictions, non convictions and charges regardless of
verify whether or not they have a criminal record.
disposition) retained by them in their files or electronic databases
accessed through the Public Safety Portal (PSP) query as well as PIRS
You must provide GPEB with the written authorization necessary to allow
and CPIC or any other Police or Court Information indices and databases
the police or other public bodies to release relevant information including
including the internet that are necessary for GPEB to perform registration
information relating to the Young Offenders Act to GPEB for the purposes
and enforcement responsibilities under the Gaming Control Act.
of registration and enforcement of the Gaming Control Act.
3. Any Organization pursuant to Section 6 (2) (a) of the Personal
The information requested in this application is collected under the
Information Protection Act (British Columbia), to disclose my personal
authority of the Gaming Control Act (SBC 2002).
information to GPEB in order for GPEB to conduct a background
investigation in accordance with the Gaming Control Act.
4. GPEB and any Police Departments, Public Bodies or Organizations
noted in paragraphs 2 and 3 above to utilize this consent to conduct any
future background checks and/or release any documents necessary to
continue registration or to approve any subsequent applications including
electronic applications, submitted for registration renewals.
Certification
I certify that all of the information provided by me in this application for
registration is true to the best of my knowledge and belief. If necessary, I will
provide my fingerprints to verify whether or not I have a criminal record.
Please ensure your application is complete.
Incomplete applications will not be processed.
I understand that any false or inaccurate statements made in this
application for registration, or failure to disclose is deemed sufficient cause
Your business will not be permitted to sell lottery products
for rejection of my application by GPEB.
until the contract manager or designate contract manager
is fully registered with the Gaming Policy and
I understand that any false or inaccurate statements made in this
Enforcement Branch.
application for registration which may be revealed subsequent to my
employment with the gaming company, could result in the suspension
Submit original applications and all supporting
and/or revocation of my registration.
documentation by mail or courier (see addresses at the
beginning of this application form).
I certify that I have read and understand the attached conditions of
registration.
Signature of applicant:
Name: (print your full name)
Effective today: (YYYY-MM-DD)
X
Keep your personal information safe. Your completed copy of this form
December 23, 2013
should be stored in a safe and secure place, or should be destroyed in a secure manner.
Page 3 of 4
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