COMANCHE NATION GAMING COMMISSION FORM … · COMANCHE NATION GAMING COMMISSION FORM Gaming License Application NUMBER CNGC-F-30-003 RESOLUTION CNGC-R …

COMANCHE NATION GAMING COMMISSION FORM Gaming License Application NUMBER CNGC-F-30-003 RESOLUTION CNGC-R-01-2013 EFFECTIVE DATE October 22, 2012 POLICIES CNGC-P-30-200

October 22, 2012 CNGC-F-30-003 Page 1 of 7

Comanche Nation Gaming Commission Gaming License Application

Personal Information

First Name: Middle Name: Last Name: Suffix:

Alias(es), Nicknames, Maiden Name, Other Name Changes, Legal or Otherwise:

Social Security Number: Birth Date: Age: Birth Country:

Birth Address: Birth City: Birth State: Birth Zip:

Birth County: Gender: Height: Weight: Eye Color: Hair Color:

Primary Phone Number: Secondary Phone Number: Email Address:

Current Property Applying For:

Distinguishing marks (scars, tattoos, etc.) Describe and indicate location:

List all languages (indicate whether spoken, written, or both):

Are you a United States Citizen: Country: Alien Registration Number:

Date Naturalized: Place: Are you eligible for employment in this country:

If naturalized, certificate number:

Driver License Information (Past Five (5) Years)

Driver License Number: State: Expiration:





Tribal Affiliation

Are you a Tribal Member: Affiliation: Enrollment #: Location:

Military Information

Have you ever serviced in the armed forces: Start Date: End Date: Branch of Service:

State: Rank at Discharge: Serial Number:

While in the military, were you ever charged with any offense or disciplined (if yes, provide details):

Related Workers

Do you have any family members who currently work for Comanche Nation Entertainment or Comanche Nation Gaming Commission:


Current Residential Information

Physical Address:

City: State:

County: Zip Code:

Mailing Address (if different than above):

City: State:

County: Zip Code:

Educational History

From Date: To Date: School Name:

Education Level: Completed: City: State:

Degree/Major: Country:





Education Level: Completed: City: Education Level:






Education Level: Completed: City: Education Level:


Spouse Information

Full Name (Maiden): Date of Marriage: Date of Birth:

Place of Birth: Contact Phone Number: Occupation:

Employer: Employer Address:

Former Marriages(s)

Have you ever been divorced?

Full Name (Maiden): Date of Marriage: Date of Divorce:

Date of Birth: Place of Birth: Occupation:





Family Information

Children and/or Dependents

Child Name: Date of Birth: Place of Birth:

Contact Phone Number: Occupation: Physical Address:










Co-habitants and/or Roommates Co-habitant/Roommate Name: Date of Birth: Place of Birth:


Co-habitant/Roommate Name: Date of Birth: Place of Birth:








Parents, Step-Parents, Brothers and Sisters Mother/Father/Sibling’s Name: Date of Birth: Place of Birth:


Mother/Father/Sibling’s Name: Date of Birth: Place of Birth:








Employment History (Past Five (5) Years)

From Date: To Date: Employer: Title:

Address:

City: State:

Zip: Country:

Gambling Related: Name of Supervisor: Telephone Number:

Reason for Leaving:

Description of Duties:

Gap Explanation:


Address:

City: State:

Zip: Country:


Reason for Leaving:


Gap Explanation:


Address:

City: State:

Zip: Country:


Reason for Leaving:



Gap Explanation:


Address:

City: State:

Zip: Country:


Reason for Leaving:


Gap Explanation:


Address:

City: State:

Zip: Country:


Reason for Leaving:


Gap Explanation:


Address:

City: State:

Zip: Country:


Reason for Leaving:


Gap Explanation:


Address:

City: State:

Zip: Country:


Reason for Leaving:


Gap Explanation:


Address:

City: State:

Zip: Country:


Reason for Leaving:



Gap Explanation:


Address:

City: State:

Zip: Country:


Reason for Leaving:


Gap Explanation:


Address:

City: State:

Zip: Country:


Reason for Leaving:


Gap Explanation:

Residential History (Past Five (5) Years)

Move-In Date: Move-Out Date: Type: Country:

Address: City: State: Zip:
























References (Must List Three References)

First Name: Middle Name: Last Name: Relationship:


Home Phone: Work Phone:







Business Interests Have you been associated with any businesses, corporations and partnerships in the past 15 years as an owner, officer, director, active shareholder, partner, or other related capacity?

Describe all previous or existing business relationships with any Indian Tribe, including any ownership interest in those businesses:

Describe any existing or previous business relationships with the gaming industry, including any ownership interest in those businesses:

Other Licensing Information

Have you ever held or applied for a permit, license, or certificate related to gaming, whether or not such license, permit, or certificate was granted?

Have you ever held or applied to a licensing or regulatory agency for an occupational license, permit, or certificate whether or not such a license, permit, or certificate was granted?

Have any disciplinary actions ever been taken, or any such actions pending, for any of the above listed licenses, permits, and/or certificates?

Have you ever appeared before any licensing agency, similar authority either inside or outside the State of Oklahoma, for any reason whatsoever (if yes, provide details)?

Criminal History Information

Have you EVER been convicted of or charged with a felony?

Are you currently being prosecuted for a felony?

Have you EVER been charged or convicted for a misdemeanor (excluding traffic violations) within ten (10) years of date of application?

Are there currently charges pending against you for any criminal offense - felony or misdemeanor?

Have you EVER had any criminal charges filed against you (excluding minor traffic charges) whether or not convicted including a DUI and DWI within ten (10) years of date of application?


Have you EVER had a deferred sentence for a criminal charge filed against you within ten (10) years of date of application?

Have you EVER had any charges filed against you that were dismissed?

Have you EVER served a sentence, including probation or parole, upon conviction for any felony or misdemeanor within ten (10) years of date of application?

Have you EVER received a pardon for any criminal acts?

Have you EVER had any charges filed against you expunged from your record?

Have you EVER been arrested, detained, charged, indicted, or summoned to answer for any charges related to fraud, embezzlement, theft, or burglary for any reason regardless of the disposition of the event?

Have you EVER been arrested, detained, charged, indicted, or summoned to answer for any gambling related offense, fraud, or misrepresentation in any connection for any reason regardless of the disposition of the event?

Financial History Information

Have you ever filed bankruptcy, in any jurisdiction?

Have you ever been a plaintiff or defendant in a civil suit and/or had a judgement or lien rendered against you?

Have you ever had your state or federal personal income tax return audited or adjusted?

Additional Information

Submitted By Date

Documents

COMANCHE NATION GAMING COMMISSION FORM … · COMANCHE NATION GAMING COMMISSION FORM Gaming License Application NUMBER CNGC-F-30-003 RESOLUTION CNGC-R …