Gaming Application

Position Applied For: *

Date:

Name: *

First

Middle

Last

Other Names (Aliases, Maiden or other Married Names):

The National Indian Gaming Commission requires that the following notices be printed verbatim before you complete this application:

In compliance with the Privacy Act of 1974, 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 Tribal gaming regulatory authorities 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 Federal, Tribal, 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 a tribe or the NIGC in connection with the issuance, denial, or revocation of a gaming license, or investigations of activities while associated with a tribe or a gaming operation. Failure to consent to the disclosures indicated in this notice will result in a tribe's 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. 25 CFR §556.2 A false statement on any part of your license application may be grounds for denying a license or the suspension or revocation of a license. Also, you may be punished by fine or imprisonment (U.S. Code, title 18, section 1001). 25 CFR §556.3

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. Kootenai Tribal Gaming Commission P.O. Box 1269 Bonners Ferry, ID 83805 Ph (208) 267-3519 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.

Signature of Applicant: *

Clear Signature

Date:

Gender:

Male
Female

Date of Birth: *

Citizen of U.S.? *

Yes
No

Citizen of what Country?

Any Foreign Languages (spoken or written)?

Social Security Number: *

Place of Birth:

(City, County, State)

The National Indian Gaming Commission Regulations at 25 CFR §556.4(2) require the following information: Currently and for the previous five years: Business and employment positions held, ownership interests in those businesses, business and residence addresses, and driver's license numbers. Use separate paper if necessary.

Current Driver's License # & State Issued *

All other Driver's Licenses, including state and license numbers, for the previous five years: *

Current Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Phone: *

All Residences for the previous five years:

(City, County, State, Dates you lived there)

For the previous five years, all business and employment positions held, ownership interests in those businesses, and business addresses:

Are you now being, or have you ever been, prosecuted or convicted of a felony? *

Yes
No

If yes, list charge, date, city, name and address of courts involved, and disposition.

Are you now being, or have you been, prosecuted or convicted of a misdemeanor (excluding minor traffic violations) in the last ten years? *

Yes
No

If yes, list charge, date, city, name and address of courts involved, and disposition.

If, within the last 10 years, you've had any criminal charges (excluding minor traffic charges) brought against you, whether or not there was a conviction, and not already listed in questions above, please list the charge, the name and address of the court and that date and disposition.

Have you owned any business, or had any interest in any business within the last ten years? *

Yes
No

If yes, list business, address, interest in business/position and dates involved.

Have you had any previous or existing business relationships, including ownership interests, with Indian tribes or the gaming industry? *

Yes
No

If yes, describe the relation, when and where.

Have you ever applied for a permit or license related to gaming? *

Yes
No

If yes, type of license, name and address of agency, and date.

Have you ever applied for any other type of occupational license or permit, whether or not such permit or license was granted? *

Yes
No

If yes, type of license, name and address of agency, and date.

Personal References

The National Indian Gaming Commission requires the names and current addresses of at least three personal references, including one personal reference who was acquainted with the applicant during each period of residence listed above. 25 CFR §556.4(3). Please list the full name, current address, and phone number of three personal references. At least one of these references should not be previously listed on the employment application, and should be someone who has been acquainted with you for the previous five years, or longer.

Reference #1 Name:

First

Last

Phone:

Current Address:

Email:

Occupation:

Years Known:

Reference #2 Name:

First

Last

Phone:

Current Address:

Email:

Occupation:

Years Known:

Reference #3 Name:

First

Last

Phone:

Current Address:

Email:

Occupation:

Years Known:

Kootenai Tribal Gaming Commission

The National Indian Gaming Commission requires that the following notices be printed verbatim before you complete this application:

Kootenai Tribe of Idaho Privacy Act Notice - Please Read Before Signing:

False Statement Notice

Consent to Jurisdiction

Personal References

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