Fillable APPLICATION FOR STATE CERTIFICATION/COMMUNITY GAMING LICENSE Salt River (Salt River Pima-Maricopa Indian Community)

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APPLICATION FOR STATE CERTIFICATION/COMMUNITY GAMING LICENSE Salt River (Salt River Pima-Maricopa Indian Community)

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SGA-901Revised 2/14/2017 – SRPMIC 901 1 Applicant’s Initials _______
Salt River Pima –Maricopa Arizona Department of Gaming
Indian Community Regulatory Agency 1110 W. Washington Street, Suite 450
8840 E. Chaparral Road, Suite 165 Phoenix, AZ 85007
Scottsdale, AZ 85250 (602) 771-4263
Date__________________
APPLICATION FOR STATE CERTIFICATION/COMMUNITY GAMING LICENSE
Type or print an answer to every question. Do not leave any spaces blank. If a question does not apply to you, mark the space
with ‘None’. Do not use N/A. If you do not have enough space, continue writing your answers on page 14, or use a separate sheet.
Be sure to mark each answer with the same number as the question. Answer each question with complete and truthful answers and
do not leave any information out. Information on the application form will be reviewed and verified. You must place your
initials in the lower right hand corner of each page to indicate that you have correctly answered each question on that page.
If you do not understand a question, or need help completing the form, please call the Tribal Gaming Office.
Applicant Initials___
__
Salt River Pima-Maricopa Indian Community Tribal Gaming
Facilities
Are you an enrolled Tribal Member of this Community?
Yes No
Tribal Affiliation
Tribal Enrollment/Identification Number
Position Applying For
Are you associated with a business applying for State Certification?
Yes No
Department (Security, Table Games, IT, ETC)
1. PERSONAL INFORMATION
Certificate of Naturalization or Alien Registration Card must be included with this
application.
FOR OFFICIAL USE ONLY
Applicant ID#___________________
CGL No.________________
Temp Issue Date_________________
Last Name
First Name Middle Name
Alias, Nicknames, Maiden Name, Other Name Changes, Legal or Otherwise
Place of Birth (City, State)
Sex
Age
Social Security Number
Color of Eyes
Color of Hair
Height
Weight
Drivers License Number and State
Mailing Address
City, State and Zip Code
Sex
Age
Residence Address (if different from Mailing)
City, State and Zip Code
Residence Phone (include area code)
Cell or Other Phone
Email Address
Are you a United States Citizen?
Yes □ No □
If no, what country?
Alien Registration Number and Expiration Date
Are you a Naturalized Citizen?
Yes □ No □
Certificate of Naturalization Number
Date Naturalized
Place Naturalized (City, State)
SGA-901Revised 2/14/2017 – SRPMIC 901 2 Applicant’s Initials _______
1. PERSONAL INFORMATION Continued
Current Occupation
Business Phone (include area code)
Languages Spoken (other than English)
Languages Written (other than English)
Scars, tattoos or distinguishing marks and/or characteristics
2. MARITAL INFORMATION
Single Married Separated Divorced Widowed
Complete the information below if you are Married, Separated or if your Divorce is pending.
Date of Marriage
Place of Marriage (City and State)
Spouse’s Full Name (Maiden)
Spouse’s Social Security No.
Date of Birth
Place of Birth (City and State)
Residence Address
City, State, and Zip Code
Residence Phone (include area code)
Business Phone (include area code)
3. EDUCATION
Type
Name of School
Location (City, State)
Dates Attended
Graduate
(Yes or No)
High School
College / University
Other
Type of Degree(s) _______________________________________________________________________________
Sensitive Management Positions/Key Employees: Attach a copy of your Certificate,
Diploma or Degree
SGA-901Revised 2/14/2017 – SRPMIC 901 3 Applicant’s Initials _______
4. MILITARY INFORMATION
Have you ever served in the armed forces? Yes No
If the answer is yes, complete the following information and PROVIDE MEMBER COPY 4 OF DD Form 214.
Branch _________________________ Serial No. __________________________ Date of Entry ____________________
Date of Separation _________________ Type of Discharge ___________________ Rank at Separation _______________
While in the military service, were you ever arrested or charged for an offense that resulted in non-judicial punishment
or trial by court martial? If yes, you MUST provide a full explanation of the circumstances of any arrest on page 14.
Yes No
5. RESIDENCES
Beginning with your current residence, list all your residences for the past 10 years or since your 18
th
birthday.
Month and Year
Street Address
City, State and Zip Code
From
City
To
State, and Zip Code
From
City
To
State, and Zip Code
From
City
To
State, and Zip Code
From
City
To
State, and Zip Code
From
City
To
State, and Zip Code
From
City
To
State, and Zip Code
From
City
To
State, and Zip Code
SGA-901Revised 2/14/2017 – SRPMIC 901 4 Applicant’s Initials _______
5. RESIDENCES continued
From
City
To
State, and Zip Code
From
City
To
State, and Zip Code
From
City
To
State, and Zip Code
From
City
To
State, and Zip Code
6. CHARACTER REFERENCES
List five individuals who know you well enough to be used as character references. Do not include relatives,
present employer.
Name and Where Employed
Street, City, State and Zip Code
Phone
Years
Known
Name
Residence Address
Employer
Business Address
Name
Residence Address
Employer
Business Address
Name
Residence Address
Employer
Business Address
Name
Residence Address
Employer
Business Address
Name
Residence Address
Employer
Business Address
SGA-901Revised 2/14/2017 – SRPMIC 901 5 Applicant’s Initials _______
7. EMPLOYMENT/PERIODS OF UNEMPLOYMENT
Beginning with your current employment, list your work history, all businesses with which you have been involved, and/or all
periods of unemployment, for the past 10 years or since your 18th birthday. In addition, list all corporations, partnerships or
any other business ventures with which you have been associated as an officer, director, stockholder, or related capacity. Reason
for leaving must include whether you were terminated, laid-off, resigned, quit, etc., and provide a full explanation. All
employment/termination is subject to verification.
From
Employer Name
Business Phone
Is the company working in
the Gaming industry?
Yes No
To
Employer Address
City, State and Zip Code
Job Title
Description of Duties
Name of Supervisor
Provide detailed reason for leaving:
From
Employer Name
Business Phone
Is the company working in
the Gaming industry?
Yes No
To
Employer Address
City, State and Zip Code
Job Title
Description of Duties
Name of Supervisor
Provide detailed reason for leaving:
From
Employer Name
Business Phone
Is the company working in
the Gaming industry?
Yes No
To
Employer Address
City, State and Zip Code
Job Title
Description of Duties
Name of Supervisor
Provide detailed reason for leaving:
From
Employer Name
Business Phone
Is the company working in
the Gaming industry?
Yes No
To
Employer Address
City, State and Zip Code
Job Title
Description of Duties
Name of Supervisor
Provide detailed reason for leaving:
From
Employer Name
Business Phone
Is the company working in
the Gaming industry?
Yes No
To
Employer Address
City, State and Zip Code
Job Title
Description of Duties
Name of Supervisor
Provide detailed reason for leaving:
SGA-901Revised 2/14/2017 – SRPMIC 901 6 Applicant’s Initials _______
8. CIVIL LITIGATION/PROFESSIONAL LICENSES/GAMING INFORMATION
Please read each question carefully. Provide detailed explanation as necessary
A. For the past 10 years or since your 18
th
birthday, have you, as an individual, member of a partnership, LLC
or owner, director, or officer of a corporation, ever been a party to a lawsuit as either a plaintiff or defendant?
Yes No
If you answered yes, you must provide the following details below. List all cases without exception. Provide
additional information on page 14 or attached additional sheet(s) as necessary.
Plaintiff/Defendant
Court and Case Number
City, County, and State
Date and Disposition
Plaintiff
Court
City
Date
Defendant
Case No.
County and State
Disposition
Reason for Civil Action
Plaintiff
Court
City
Date
Defendant
Case No.
County and State
Disposition
Reason for Civil Action
Plaintiff
Court
City
Date
Defendant
Case No.
County and State
Disposition
Reason for Civil Action
Plaintiff
Court
City
Date
Defendant
Case No.
County and State
Disposition
Reason for Civil Action
SGA-901Revised 2/14/2017 – SRPMIC 901 7 Applicant’s Initials _______
B. Have you ever held a privilege or professional license or certification including but not limited to the
following in any state? Yes No
Real Estate Broker or Salesman
Racehorse/Dog Owner
Accountant
Police Officer
Insurance Salesman
Racehorse/Dog Trainer
Doctor
Security Officer
Securities Dealer
Racehorse/Dog Manager
Lawyer
Private Investigator
General Contractor
Architect
Jockey
Nurse
Liquor License
If you answered yes, state what type license, where issued, and years held.
C. Have you ever held a financial interest in a gambling venture, including a racetrack, dog track, racehorse or dog,
lottery, casino, bookmaking operation, or pari-mutuel operation outside the State of Arizona?
Yes No
If you answered yes, provide the following information on page 14. State what type, when and where held, names/
locations of the businesses in which you were involved and the names/addresses of all partners and principals.
D. Have you as an individual, or as a participant in a group, ever been granted a gaming license/state certification in or
outside the State of Arizona?
Yes No
If you answered yes, state the type of license, name of the issuing jurisdiction or Indian Tribe, location, and period
held.
E. Have you ever been disciplined by, or appeared before any licensing agency or similar authority in or outside the
State of Arizona for any reason?
Yes No If you answered yes, you must provide the details.
SGA-901Revised 2/14/2017 – SRPMIC 901 8 Applicant’s Initials _______
F. Have you as an individual, or as a participant in a group, had a tribal or gaming license denied, revoked,
suspended, forfeited or withdrawn by any gaming authority in any jurisdiction or any country?
Yes No
If you answered yes, state where, when and for what reason.
G. Have you as an individual, or as a participant in a group, ever:
1. been terminated from any gaming facility in any jurisdiction or country?
Yes No
2. resigned to avoid being terminated from any gaming facility in any jurisdiction or country?
Yes No
3. been banned or barred from any gaming facility in any jurisdiction or country?
Yes No
If you answered yes, state where, when and for what reason.
H. Have you ever placed your name on a list of people self-excluded from any gaming facility?
Yes No
If you answered yes, state where you self-excluded, the date of your self-exclusion and the length of time you elected
to self-exclude. Submit a copy of your self-exclusion form with this application.
_________ I agree to waive any confidentiality of the attached self-exclusion form for the purpose of allowing the
Department of Gaming to process my application for State Certification/Tribal License Recommendation.
I. Do you have any relatives associated with or employed at the Department of Gaming, Racing Division or the
Boxing and Mixed Martial Arts Commission?
Yes No
If you answered yes, state the name, relationship, and association or employment.
SGA-901Revised 2/14/2017 – SRPMIC 901 9 Applicant’s Initials _______
9. FINANCIAL INFORMATION
If the answer to any question yes, please provide the details on page 14.
A. Do you anticipate active participation in the management of the gaming facility?
Yes No
B. Have you ever personally filed for relief from creditors under the Federal Bankruptcy Code?
Yes No
C. Has your Federal Personal Income Tax Return ever been audited or adjusted?
Yes No
D. Has your State Personal Income Tax Return ever been audited or adjusted?
Yes No
E. Have you ever failed to file any required State or Federal Income Tax Return?
Yes No
F. Last Federal Income Tax Return filed: Date _________________________________________
G. Last State Income Tax Return filed: Date _________________________________________
H. Total annual income from last tax year filed (all sources) $ __________________________________
I. Do you own or control any assets or liabilities outside the United States?
Yes No
J. Do you control, manage, or hold in trust any assets or liabilities for another person or entity?
Yes No
SGA-901Revised 2/14/2017 – SRPMIC 901 10 Applicant’s Initials _______
9. FINANCIAL INFORMATION continued
K. List all current Sources of Income
INCOME
SOURCE OF INCOME
AMOUNT
Salary
Interest
Dividends
Other sources, such as child support,
alimony, etc. (describe in detail)
MORTGAGES PAYABLE
Name and Address of Creditor
Date Incurred
Original Amount
Unpaid
Balance
Payment/Period
Interest
Rate
Maturity
Date
Description/Address
of Real Estate
$
Total
IF THIS SCHEDULE DOES NOT APPLY TO YOU, PLEASE WRITE NONE ACROSS THE ENTIRE SCHEDULE
NOTES PAYABLE
Complete the information listed below for all notes payable other than mortgages (car loans, bank loans, student loans, credit
cards, etc.) for which you, your spouse, and/or dependent children are obligated. Indicate by means of an asterisk (*) in the first
column, those notes payable for which your spouse and/or dependent children are obligated.
Name and Address of Creditor
Date Incurred
Original Amount
Unpaid
Balance
Payment/Period
Interest
Rate
Maturity
Date
Purpose
$
Total
IF THIS SCHEDULE DOES NOT APPLY TO YOU, PLEASE WRITE NONE ACROSS THE ENTIRE SCHEDULE
SGA-901Revised 2/14/2017 – SRPMIC 901 11 Applicant’s Initials _______
10. CRIMINAL HISTORY
ARRESTS and DETENTIONS
The questions below refer to all arrests, detentions, charges, indictments, citations or summons to
answer for any criminal offense or violation for any reason whatsoever (except minor traffic
violations), regardless of the disposition of the event, dismissals, expunged/sealed or restoration of civil
rights. If your answer to any question (A through G) is yes, you must provide a full explanation of the
circumstances on the Arrest Disclosure Form following this section.
A. Have you EVER been charged with a criminal offense or arrested? Yes No
B. Have you EVER been convicted of a felony? Yes No
C. Has a criminal indictment, information, or complaint ever been returned against you in which you were not
arrested or in which you were named as an unindicted co-party? Yes No
D. Have you ever been questioned by a city, state, federal, or tribal law enforcement agency, commission or
committee for any crime you may have been suspected of?
Yes No
E. Have you ever been subpoenaed to appear or testify before a grand jury, court, board, or commission?
Yes No
F. Have you ever had a civil or criminal record expunged or sealed by a court order?
Yes No
G. Have you ever received a pardon for any criminal offense?
Yes No
H. Has any member of your immediate family ever been convicted of a felony or a gaming offense?
Yes No If you answered yes, you must provide the following information:
Name
Relationship
Charge
Location (City, State)
Date
SGA-901Revised 2/14/2017 – SRPMIC 901 12 Applicant’s Initials _______
Arrest Disclosure Form
Attach or obtain documents you received from the court showing the final disposition of the charges.
(If your unable to obtain documentation, provide the name and number of the court clerk you spoke with)
Provide full details of the circumstances below each charge. Use additional sheet(s) as necessary.
Date arrested/charged:
Agency that arrested/charged you:
Offense/Charge (s):
Court where you appeared:
Disposition / Current Status (Jail, Fine, Probation):
Date arrested/charged:
Agency that arrested/charged you:
Offense/Charge (s):
Court where you appeared:
Disposition / Current Status (Jail, Fine, Probation):
Explanation:
Explanation:
SGA-901Revised 2/14/2017 – SRPMIC 901 13 Applicant’s Initials _______
Arrest Disclosure Form
Attach or obtain documents you received from the court showing the final disposition of the charges.
(If your unable to obtain documentation, provide the name and number of the court clerk you spoke with)
Provide full details of the circumstances below each charge. Use additional sheet(s) as necessary.
Date arrested/charged:
Agency that arrested/charged you:
Offense/Charge (s):
Court where you appeared:
Disposition / Current Status (Jail, Fine, Probation):
Date arrested/charged:
Agency that arrested/charged you:
Offense/Charge (s):
Court where you appeared:
Disposition / Current Status (Jail, Fine, Probation):
Explanation:
Explanation:
SGA-901Revised 2/14/2017 – SRPMIC 901 14 Applicant’s Initials _______
ADDITIONAL INFORMATION
Provide the section or question # for each disclosure or additional information. Attach additional pages as necessary.
SGA-901Revised 2/14/2017 – SRPMIC 901 15 Applicant’s Initials _______
APPLICANT NOTIFICATIONS
You are advised that this application is an official document and false or incomplete answers could result
in criminal prosecution and the denial or subsequent revocation of State Certification or negative
recommendation of Tribal License Recommendation. Applicants Initials_____
Please be advised this application for certification is valid only for authorized Arizona gaming facilities.
Employees of any location considered by the State to be unauthorized, or in pending litigation with the
State concerning whether it is authorized, would be outside the approval granted through State
Certification. Employees of unauthorized facilities may be subject to legal and/or regulatory risks.
Applicant’s Initials_____
You are further advised that this application may not be withdrawn without the permission of the
Department of Gaming. Applicants Initials____
Under the Federal Privacy Act, disclosure of social security numbers is voluntary unless a statute
specifically requires it or allows states to collect the number. In this instance, disclosure of your social
security number is mandatory pursuant to Title 42 United States Code, Sections 405(c)(2)(c), and
Sections 653, 654, and 666; and A.R.S. § 25-320(P) in order to aid the Department of Economic Security
in locating non-custodial parents or the assets of non-custodial parents.
Applicants Initials_____
Pursuant to A.R.S. § 41-1030:
B. An agency shall not base a licensing decision in whole or in part on a licensing requirement or
condition that is not specifically authorized by statute, rule or state tribal gaming compact. A general
grant of authority in statute does not constitute a basis for imposing a licensing requirement or
condition unless a rule is made pursuant to that general grant of authority that specifically authorizes
the requirement or condition.
D. This section may be enforced in a private civil action and relief may be awarded against the state.
The court may award reasonable attorney fees, damages and all fees associated with the license
application to a party that prevails in an action against the state for a violation of this section.
E. A state employee may not intentionally or knowingly violate this section. A violation of this
section is cause for disciplinary action or dismissal pursuant to the agency’s adopted personnel policy.
F. This section does not abrogate the immunity provided by section 12-820.01 or 12-820.02.
Applicants Initials_____
This information is intended for the sole use of the Arizona Department of Gaming and the Salt River
Pima-Maricopa Indian Community Regulatory Agency.
SGA-901Revised 2/14/2017 – SRPMIC 901 16 Applicant’s Initials _______
APPLICANT CHECKLIST
By checking each box, I verify that I have read and understand the statements and have attached any
requested documents.
I have provided a valid mailing address, phone number and email address. I understand that the
Arizona Department of Gaming is not responsible for any correspondence not received.
Please be advised that the address listed on page 1, will be used for mailing all notices or other
communication. It is the sole responsibility of the licensee to notify the Department of a change in mailing
address.
I have listed all arrests, detentions, charges, indictments, criminal citations for any criminal offense.
(except minor traffic)
I have provided court documents showing disposition or current case status of all disclosed arrests.
Optional: I agree to receive notices and communications by email if allowable by law. I understand I
have the right to withdraw this permission by contacting the Arizona Department of Gaming in
writing.
I, _________________________________, hereby acknowledge and say that this application is true and correct to the
best of my knowledge. This application is being executed with the knowledge that false or incomplete answers could
result in criminal prosecution and the denial of, or subsequent revocation of, state certification or negative
recommendation of tribal license recommendation by the Arizona Department of Gaming. Further, that I am
voluntarily submitting this application with full knowledge that it will be reviewed by appropriate Tribal and State
authorities charged by law with granting gaming licenses and state certifications/tribal license recommendations.
________________________________________________
Signature of Applicant
ATTACH A PHOTOGRAPH
TAKEN WITHIN THE
LAST 30 DAYS
DO NOT STAPLE
SGA-902 Revised 2/14/2017 – SRPMIC 901 17 Applicant’s Initials
_______
RELEASE OF ALL CLAIMS
The undersigned has filed with the Arizona Department of Gaming an Application for State
Certification/ Recommendation. In consideration of the assurance by the Department of Gaming that no
decision on said application will be taken except after a deliberate, intensive and thorough investigation of the
undersigned, including but not limited to background, associates, and finances, the undersigned does for myself,
my heirs, executors, administrators, agents, representatives, successors and assigns, hereby release and forever
discharge the State of Arizona, the Department of Gaming, its members, agents, and employees, from all
manner of actions, causes of action, suits, debts, judgments, executions, claims and demands whatsoever,
known or unknown, in law or equity, which the undersigned ever had, now has, may have, or claim to have
against any or all of said entities or individuals arising out of or by reason of the processing or investigation of
or other action relating to the undersigned application.
I, the undersigned, have read this release and understand all its terms. I execute it voluntarily and with
full knowledge of its significance.
I have executed this Release of All Claims on this _______day of __________________, 20______.
______________________________________________
Applicant Signature
SGA-903 Revised 2/14/2017 – SRPMIC 901 18 Applicant’s Initials_______
APPLICANT'S REQUEST TO RELEASE INFORMATION
TO __________________________________________________________________________________________
Leave Blank - To Be Completed By The Department of Gaming
FROM _______________________________________________________________________________________
Applicant's Name
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
this application.
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______.
______________________________________________
Applicant Signature
State of __________________
County 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.
______________________________________________
Notary Public
Signature of the Arizona Department of
Gaming Agent presenting this request:
_____________________________________
Date _________________________________
SRPMIC Revised 03/01/2017 19 Applicant’s Initials_______
Criminal History Record Information
Disclosure of Privacy Requirements
Your fingerprints will be used to check the criminal history records of the FBI.
The use of the FBI criminal history record information will be used to assist in the determination of
suitability for the issuance of State Certification or Tribal Licensing for employment in, or providing goods or
services to the Arizona Tribal Gaming Industry.
You may request procedures for obtaining a copy of your record for a change, correction, or updating of an
FBI criminal history record as set forth in Title 28, Code of Federal Regulations (CFR) Section 16.30 through
16.34. Information on how to review and challenge your FBI criminal history record can be found at
www.fbi.gov or by calling (304) 625-3878. If requested you will be given a reasonable period of time to
complete or challenge the accuracy of the information.
To obtain a copy of your Arizona criminal history in order to review/update/correct the record, you can
contact the Arizona Department of Public Safety Criminal History Records Unit at (602) 223-2222 to obtain
a fingerprint card and a Review and Challenge Packet. Information on the review and challenge process can
be found at the DPS website (www.azdps.gov).
Criminal history record information is solely for the purpose stated and cannot be disseminated outside the
Department of Gaming, Tribal Gaming Office or other authorized entity.
You may retain a copy of this signed disclosure if desired.
By my signature below, I fully acknowledge that I have read and understand this disclosure.
________________________________ __________________________________________ ___________________
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APPLICATION FOR STATE CERTIFICATIONCOMMUNITY GAMING LICENSE Salt River (Salt River Pima-Maricopa Indian Community)

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Completed 20 July 2020

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