Kootenai Tribe of Idaho Privacy Act Notice - Please Read Before Signing:
In compliance with the Privacy Act of 1974 and the Kootenai Tribe Privacy Act (Kootenai Law
and Order Code Chapter 30), the following information is provided: Solicitation of the
information on this form is authorized by 25 U.S.C. 2701 et seq.
The purpose of the requested information is to determine the eligibility of individuals to be
granted a gaming license. The information will be used by the Kootenai Tribal Gaming
Commission (KTGC) and by the National Indian Gaming Commission (NIGC) members and
staff who have need for the information in the performance of their official duties. The
information may be disclosed by the Tribe or the NIGC to appropriate Tribal, Federal, State,
local, or foreign law enforcement and regulatory agencies when relevant to civil, criminal or
regulatory investigations or prosecutions or when pursuant to a requirement by the Tribe or the
NIGC in connection with the issuance, denial, or revocation of a gaming license, or
investigations of activities while associated with the Tribe or a gaming operation.
Failure to consent to the disclosures indicated in this notice will result in the Tribe or other
gaming regulatory authorities being unable to license you for a primary management official or
key employee position.
The disclosure of your Social Security Number (SSN) is voluntary. However, failure to supply a
SSN may result in errors in processing your application.
False Statement Notice
A false statement on any part of your application may be grounds for the Kootenai Tribal
Gaming Commission to not license you, or to suspend or revoke your gaming license after you begin work. Also, you may be punished by fine or imprisonment (Kootenai Law & Order Code,
Section 4-19; U.S.C., Title 18, Section 1001.)
Consent to Jurisdiction
Any person who applies for any license or employment, enters into any contract or agreement
with the Kootenai Tribe of Idaho, or Kootenai Tribal entity shall be deemed to consent to the civil
jurisdiction of the Tribe and the Tribal Court.
(City, County, State, Dates you lived there)
Please list the name and current address of at least one personal reference, not previously
listed on the employment application, who has been acquainted with you for the previous five
years, or longer.