SGA-903 Revised 2/14/2017 – SRPMIC 901 18 Applicant’s Initials_______
APPLICANT'S REQUEST TO RELEASE INFORMATION
Leave Blank - To Be Completed By The Department of Gaming
1. I hereby authorize and request all persons to whom this request is presented having information relating to or concerning me to
furnish such information to a duly appointed agent of the Arizona Department of Gaming, whether or not such information would
otherwise be protected from disclosure by any constitutional, statutory or common law privilege.
2. I hereby authorize and request all persons to whom this request is presented having documents relating to or concerning me to
permit a duly appointed agent of the Arizona Department of Gaming to review and copy any such documents, whether or not such
documents would otherwise be protected from disclosure by any constitutional, statutory, or common law privilege.
3. If the person to whom this request is presented is a brokerage firm, bank, savings and loan, or other financial institution or an
officer of the same, I hereby authorize and request that a duly appointed agent of the Arizona Department of Gaming be permitted
to review and obtain copies of any and all documents, records or correspondence pertaining to me, including but not limited to past
loan information, notes co-signed by me, checking account records, savings deposit records, safe deposit records, passbook
records, and general ledger folio sheets.
4. I have filed with the Arizona Department of Gaming an "application" for certification. I understand that I am seeking certification
and acknowledge that the burden of proving my qualifications for a favorable determination is at all times on me. I accept any risk
of adverse public notice, embarrassment, criticism, or other action of financial loss which may result from action with respect to
5. I do, for myself, my heirs, executors, administrators, agents, representatives, successors and assigns (collectively, “Indemnitors”),
hereby release and forever discharge the person to whom this request is presented, and his agents and employees (collectively,
“Indemnitees”) from all manner of actions, causes of action, suits, debts, judgments, executions, claims, demands whatsoever,
known or unknown, in law or equity, which I ever had, now have, may have, or claim to have against the Indemnitees arising out of
or by reason of complying with this request.
6. I, for myself and Indemnitors, agree to indemnify and hold harmless the Indemnitees from and against all claims, damages, losses,
and expenses, including reasonable attorneys' fees arising out of, or by reason of, complying with this request.
7. A reproduction of this request by photocopy or similar process shall be for all intents and purposes as valid as the original.
8. This authorization expires eighteen (18) months from the date of execution.
I have executed this request/release/authorization on this _______day of ___________________________, 20______.
State of __________________
On this____________ day of ___________________, 20_______, before me personally appeared
_______________________________________(name of signer), whose identity was proven to me on the basis of satisfactory
evidence to be the person whose name is subscribed to this document, and acknowledged that he/she executed the same.
Signature of the Arizona Department of
Gaming Agent presenting this request: