Fillable Form 1.: SALT RIVER PIMA-MARICOPA INDIAN COMMUNITY (Salt River Pima-Maricopa Indian Community)

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Form 1.: SALT RIVER PIMA-MARICOPA INDIAN COMMUNITY (Salt River Pima-Maricopa Indian Community)

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CRA Rev 5/16
Applicant’s Initial__________
1
1.
SALT RIVER PIMA-MARICOPA INDIAN COMMUNITY
COMMUNITY REGULATORY AGENCY
8840 E. Chaparral Rd. Suite 165, Scottsdale AZ 85250
(480) 362-5450
GAMING SUPPORT EMPLOYEE / NON-GAMING APPLICATION (4B)
A) In compliance with the rules and regulations of the National Indian Gaming Commission, the Tribal-State Compact
and the Gaming Ordinance of the Salt River Pima-Maricopa Indian Community Regulatory Agency, every gaming
employee must be licensed by the Community Regulatory Agency. Background and criminal checks are required
of every applicant for a tribal gaming license. The Community Regulatory Agency, shall either issue a tribal gaming
license or deny the application.
Your application will not be accepted without the following required items:
B. Requested documents and ID’s:
All applicants must provide their Social Security Card
and
US Citizen—a valid State Driver License or valid State ID.
Naturalized Citizen—Certificate of Naturalization. (must provide original Certificate)
Non-US Citizen or Resident Alien—Permanent Residence or Work Authorization Card
C. Additional required documents if applicable.
Submit Military form, DD214 (if you have served in the military).
Tribal ID (If you are an enrolled member of a Native American Tribe.)
D. Notarization Requirements—Agents of the CRA can notarize the documents contained in this application.
However, we require a valid unexpired State or Territory of the United States Driver’s License or Identification Card.
CRA Rev 5/16
Applicant’s Initial__________
2
2.
A) PRIVACY NOTICE
1. In compliance with the Privacy Act of 1974, the following information is provided: Solicitation of the
information on this form authorized by 25 U.S.C. 2701 et seq. The purpose of the requested information is to
determine the eligibility of individuals to be employed in the gaming operation. The information will be used
by the Community Regulatory Agency, State Gaming Agency, National Indian Gaming Commission members
and staff who have need for the information in the performance of their official duties. The information may
be disclosed 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 Community Regulatory Agency in connection with the hiring or firing of an employee, the
issuance or revocation of a gaming license, or investigations of activities while associated with a tribe or
gaming operation. Failure to consent to the disclosures indicated in this notice will result in a tribe’s being
unable to hire you.
2. The foregoing Privacy Notice is applicable to all Gaming Employee Applicants.
3. The disclosure of your Social Security Number (S.S.N) is voluntary. However, failure to supply a Social
Security Number may result in errors in processing your application.
B) NOTICE REGARDING CRIMINAL HISTORY:
1. The criminal background investigation will reveal all criminal history. Therefore you must disclose all
adult criminal history since your 18th birthday. This includes any arrests, citation in lieu of arrest,
criminal charges and convictions.
2. You must disclose all charges even if they were dismissed or no charges were filed.
3. A false statement on any part of your application may be grounds for denial of a gaming license.
C) CRIMINAL CONVICTIONS AS GROUNDS FOR REVOCATION OR SUSPENSION.
1. The Community Regulatory Agency may revoke or suspend the license or finding of suitability of a person
who is convicted of a crime, even though the convicted person’s prior conviction rights and remedies have
not been exhausted, if the crime or conviction discredits or tends to discredit the Salt River Pima-Maricopa
Indian Community.
2. I ,(PRINT NAME) __________, UNDERSTAND THAT I MUST
NOTIFY THE COMMUNITY REGULATORY AGENCY, LICENSING DEPARTMENT (IN PERSON) WITHIN
72 HOURS OF ANY ARREST, CRIMINAL INDICTMENT, COMPLAINT OR ANY INFORMATION, WHICH
MAY CHANGE THE STATUS OF MY LICENSE WHILE HOLDING A LICENSE ISSUED BY THE
COMMUNITY REGULATORY AGENCY. I UNDERSTAND THAT I MUST ALSO NOTIFY THE CRA DURING
THE LICENSING PROCESS, AS IT MAY AFFECT MY SUITABILITY FOR LICENSING. I UNDERSTAND
THAT THE BURDEN OF PROVING MY SUITABILITY FOR A FAVORABLE DETERMINATION IS AT ALL
TIMES ON ME.
3. RANDOM AND SCHEDULED DRUG TESTING: I understand that Casino Arizona conducts random and
scheduled drug testing and the results of this testing are reported to the Community Regulatory Agency
(CRA). I further understand that any derogatory test outcome could result in administrative action being taken
against my Community Gaming License (CGL).
_______________________________________________________
Applicant’s Signature Date
click to sign
signature
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CRA Rev 5/16
Applicant’s Initial__________
3
3.
INSTRUCTIONS
A. Type, or legibly print an answer to every question. If a question does not apply to you, write “NONE” pertaining to
that specific question. (DO NOT LEAVE ANY QUESTION BLANK).
B. If you need more space, continue on page 12 and precede each answer with the appropriate title.
C. Do not misstate or omit any information, as each statement made is subject to verification.
D. You “MUST INITIAL EACH PAGE”, as provided in the lower right hand corner. By placing your initial on each page,
you are attesting to the accuracy and completeness of the information contained on that page.
E. All applicants are advised that this application is an official document and misrepresentation or failure to
reveal information requested may be deemed to be sufficient cause for refusal of a Tribal employee gaming
license.
F. All applicants are further advised that an application for a gaming license may not be withdrawn without the
permission of the licensing agency.
G. The foregoing three (3) pages have been read and understood by the undersigned.
_______________________________________
Print Applicant’s Name
_______________________________________
Applicant’s Signature Date
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signature
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CRA Rev 5/16
Applicant’s Initial__________
4. PERSONAL HISTORY RECORD
Are you an enrolled member of the Salt River Pima-Maricopa Indian Community?
Yes No Pending
SRPMIC Tribal Enrollment No.:________________________
Other Tribe: Name of Tribe & Enrollment No.: ___________________________________________
5. PERSONAL INFORMATION
A) Position Applying For :
B) Department :
C) Full Last Name
D) Full First Name
E) Full Middle Name
F)
Alias_________________________________________________________
(i.e., Nickname, Maiden Name, Former Married Names, Other Name Changes,
Legal or Otherwise, Oral or Written).
G)
H)
Current Address:
_____________________________________
Street Address
_____________________________________
City State Zip Code
Mailing Address (if different from current address):
____________________________________________________
Street Address
____________________________________________________
City State Zip Code
CURRENT PICTURE
I) Residence Phone Number:____________________________
Cell Phone Number: ____________________________
J)
E
-
Mail Address:
K) Date of Birth ( Month / Day / Year )
(L) Place of Birth ( City, County, State, Country )
M) Age
N) Social Security #.
O) Current Driver’s License or
State ID #:
P) State of Driver’s
license or ID:
Q) Color of Eyes
R) Color of Hair
S) Weight
T) Height
U) Sex
V)
All languages spoken or written:
CRA Rev 5/16
Applicant’s Initial__________
6. MARITAL INFORMATION
Single [ ] Married [ ] Separated [ ] Divorced [ ] Widowed [ ] Engaged [ ]
Current Marriage _______________________________________________________________________________
Date City, County, State
Spouse’s Full Name (Maiden)__________________________________S.S.N._____________________________
Date of Birth_________________________ Place of Birth______________________________________________
Spouse’s Employer _______________________________________ Occupation____________________________
Spouse’s Business Phone Number _________________________
7. EDUCATION:
A) Name of School
B) Location
(City & State)
C) Dates Attended
(Years: From - To)
D)
Graduate
1) High School,
Charter
School or
GED
1)
1)
Yes ( )
No ( )
2) College/
University
2)
2)
Yes ( )
No ( )
3) Trade School
3)
3)
Yes ( )
No ( )
E)
Type of degree obtained (Associates, Bachelors, Masters or PHD):
8. MILITARY INFORMATION:
A) Have you ever served in any armed forces? Yes [ ] No [ ]
(If Yes, you must provide a copy of your DD214)
B) Date of entry-active service:
C) Branch:
D) Type of discharge:
E) Date of Separation:
F ) Serial Number:
G) Rating at Separation:
H) While in the military service were you ever arrested for an offense which resulted in, a trial or special or general
court martial? Yes [ ] No [ ] If yes, provide full explanation
on page 12.
W) Are you a Citizen of the United States? Yes [ ] No [ ]
X) If No, Provide Permanent Resident Card Number: ___________________________ Expiration Date:___________
If naturalized, Certificate Number:_________________________ Date of Naturalization:______________________
CRA Rev 5/16
Applicant’s Initial__________
9. HAVE YOU EVER BEEN ARRESTED AS AN ADULT (SINCE AGE 18): YES ( ) NO ( )
(List all arrests, charges and convictions since the age of 18 years old).
A) FOR EACH ARREST AND OR CRIMINAL CHARGE, CRIMINAL INDICTMENT, INFORMATION, OR COMPLAINT
OR ONGOING PROSECUTION / ADULT DIVERSION REFFERAL OR A CONVICTION, OR PLEA OF GUILTY OR
NO CONTEST SINCE THE AGE OF 18 YEARS OLD.
Date of Arrest
Or Date of
Charge(s)
Age
Charge(s)
Name of
Court Involved
Disposition
Date
Disposition:
(example: Fine/Jail/Guilty/
Dismissed/Classes/No
Charges filed, etc….)
1)
2)
3)
4)
5)
6)
7)
B. HAVE YOU EVER BEEN CHARGED OR CONVICTED OF A FELONY? YES [ ] NO [ ]
C. HAS A CRIMINAL INDICTMENT, INFORMATION, OR COMPLAINT EVER BEEN RETURNED AGAINST YOU
FOR WHICH YOU WERE NOT ARRESTED OR IN WHICH YOU WERE NAMED AS AN UN-INDICTED CO-
PARTY? YES [ ] NO [ ]
D. HAVE YOU EVER BEEN QUESTIONED BY A CITY, STATE, FEDERAL, TRIBAL OR LAW ENFORCEMENT
OFFICER, AGENCY, COMMISSION OR COMMITTEE? YES [ ] NO [ ]
E. HAVE YOU EVER TESTIFIED BEFORE A FEDERAL, STATE, TRIBAL OR COUNTY GRAND JURY, BOARD
OR COMMISSION? YES [ ] NO [ ]
F. HAVE YOU EVER HAD A CIVIL OR CRIMINAL RECORD VACATED, EXPUNGED OR SEALED BY A COURT
ORDER?
YES [ ] NO [ ] IF YES, WHEN? _____________ CITY, COUNTY AND STATE_______________________
G. HAVE YOU EVER RECEIVED A PARDON FOR ANY CRIMINAL OFFENSE? YES [ ] NO [ ]
IF YES, WHEN ________________ CITY, COUNTY AND STATE _____________________________________
CRA Rev 5/16
Applicant’s Initial__________
11. BUSINESS AND EMPLOYMENT:
BEGINNING WITH YOUR CURRENT JOB, list all your work history and/or all DATES of UNEMPLOYMENT for the
previous 5 years or since your 18
th
birthday, (whichever comes first). Also, list any businesses with which you have been
an owner.
Start
A) Month/Year
End
Month/Year
Name, Mailing Address of Employer / Business /City, State Zip Code
Title
Area Code / Phone No.
Extension
Name of Supervisor and Title
Do you own
Business?
Yes ( ) No ( )
Casino
Business?
Yes ( ) No ( )
Reason for Leaving: RESIGNED TERMINATED (must provide explanation for termination):
Description of Duties:
10. RESIDENCES:
List all residences you have had during the last 5 years or since your 18
th
birthday (whichever comes
first).
MONTH & YEAR
(From – To)
Example: Jan 2007 to Dec 2011
Street and Apt. Number
City
State & Zip Code
1)
1)
1)
1)
2)
2)
2)
2)
3)
3)
3)
3)
4)
4)
4)
4)
5)
5)
5)
5)
6)
6)
6)
6)
7)
7)
7)
7)
8)
8)
8)
8)
9)
9)
9)
9)
CRA Rev 5/16
Applicant’s Initial__________
Start
B) Month/Year
End
Month/Year
Name, Mailing Address of Employer/Business /City, State, Zip Code
Title
Area Code / Phone No.
Extension
Name of Supervisor and Title
Do you own
Business?
Yes ( ) No ( )
Casino
Business?
Yes ( ) No ( )
Reason for Leaving: RESIGNED TERMINATED (must provide explanation for termination):
Description of Duties:
Start
C) Month/Year
End
Month/Year
Name, Mailing Address of Employer / Business /City, State Zip Code
Title
Area Code / Phone No.
Extension
Name of Supervisor and Title
Do you own
Business?
Yes ( ) No ( )
Casino
Business?
Yes ( ) No ( )
Reason for Leaving: RESIGNED TERMINATED (must provide explanation for termination):
Description of Duties:
Start
D) Month/Year
End
Month/Year
Name, Mailing Address of Employer / Business /City, State Zip Code
Title
Area Code / Phone No.
Extension
Name of Supervisor and Title
Do you own
Business?
Yes ( ) No ( )
Casino
Business?
Yes ( ) No ( )
Reason for Leaving: RESIGNED TERMINATED (must provide explanation of termination):
Description of Duties:
CRA Rev 5/16
Applicant’s Initial__________
Start
E) Month/Year
End
Month/Year
Name, Mailing Address of Employer/Business /City, State, Zip Code
Title
Area Code / Phone No.
Extension
Name of Supervisor and Title
Do you own
Business?
Yes ( ) No ( )
Casino
Business?
Yes ( ) No ( )
Reason for Leaving: RESIGNED TERMINATED (must provide explanation of termination):
Description of Duties:
Start
F) Month/Year
End
Month/Year
Name, Mailing Address of Employer / Business /City, State Zip Code
Title
Area Code / Phone No.
Extension
Name of Supervisor and Title
Do you own
Business?
Yes ( ) No ( )
Casino
Business?
Yes ( ) No ( )
Reason for Leaving: RESIGNED TERMINATED (must provide explanation of termination):
Description of Duties:
Start
G) Month/Year
End
Month/Year
Name, Mailing Address of Employer / Business /City, State Zip Code
Title
Area Code / Phone No.
Extension
Name of Supervisor and Title
Do you own
Business?
Yes ( ) No ( )
Casino
Business?
Yes ( ) No ( )
Reason for Leaving: RESIGNED TERMINATED (must provide explanation of termination):
Description of Duties:
CRA Rev 5/16
Applicant’s Initial__________
10
12. Have you ever been refused or denied a gaming license or certification or been a participant in any group, which
has been denied a gaming license or related finding of suitability? Yes ( ) No ( )
13. If yes to the above, state where, when, and for what reason
14. Have you ever been granted a gaming license/state certification or been a participant in any group which has been
issued a gaming license/state certification by the State of Arizona? Yes ( ) No ( )
15. If yes, state type of license, name of Indian Tribe, location, and period held:
16. Have you ever had any action taken against any gaming license/state certification, including suspension or
revocation? Yes ( ) No ( )
17. If yes, state what type of action was taken, the type of license, name of issuing agency, location, and period held:
18. Do you have any relatives associated with or employed in the gaming industry? Yes ( ) No ( )
List name of Relative, Relationship, Department and Gaming Facility, (Include any relatives that conduct business
with any casinos or tribes.):
CRA Rev 5/16
Applicant’s Initial__________
11
19. Have you ever personally filed for relief from creditors under the Federal Bankruptcy Code?
Yes ( ) No ( ) If yes chapter filed ____ City, State filed ___________________ Month/Year____BB/____BB
If yes Please explain:
20. Has your Federal Personal Income Tax Return ever been audited or adjusted?
Yes ( ) No ( ) If yes state type ____________ City, State ___________________ Month/Year____BB/____BB
If yes Please explain:
21. Has your State Personal Income Tax Return ever been audited or adjusted?
Yes ( ) No ( ) If yes state type _________BBB City, State ___________________ Month/Year ____B/____BB
If yes Please explain:
22. Have you ever failed to file any required State or Federal Income Tax Return? Yes ( ) No ( )
If yes state type ___________ City _________________State ___________Month__________ Year _______
If yes Please explain:
23.
Last Federal Income Tax Return filed: Month _____________ Tax Year
filed ____________
City _____________________ State ________________________
If Never filed / Other reason please explain:
24.
Last State Income Tax Return
filed: Month_____________ Tax Year
filed _______________
City ____________________ State _______________________
If Never filed
/ Other reasons please explain:
CRA Rev 5/16
Applicant’s Initial__________
12
25. ADDITIONAL INFORMATION
CRA Rev 5/16
Applicant’s Initial__________
13
26.
AUTHORIZATION & REQUEST TO RELEASE INFORMATION
TO: The Salt River Pima Maricopa Indian Community—Community Regulatory Agency
Agency Conducting the Background Investigation
FROM:_____________________________________________________________________________________
Print Applicant’s Name
A) I hereby authorize and request all persons to whom this request is presented having information relating to or concerning me
including, but not limited to criminal history record information, or government records to furnish such information to a duly
appointed agent of the following law enforcement and Community Regulatory Agency, Salt River Police Department, Arizona
Department of Gaming, Federal Bureau of Investigation, National Indian Gaming Commission, or other Government Agency,
whether or not such information would otherwise be protected from disclosure by any constitutional, statutory or common law
privilege.
B) 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 Community Regulatory Agency of the Salt River Pima-Maricopa Indian Community, Salt
River Police Department, 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.
C) 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 same, I hereby authorize and request that a duly appointed agent of the Community Regulatory Agency of the Salt River
Pima-Maricopa Indian Community, Salt River Police Department, 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, saving deposit records, safe deposit box records, passbook records and general ledger folio
sheets.
D) This authorization ends eighteen (18) months from the date of my signature below.
E) I have filed with the Salt River Pima-Maricopa Indian Community, Community Regulatory Agency an “application” for a license. I
understand that I am seeking the granting of a privilege 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.
F) I agree to indemnify and hold harmless the person to whom this request is presented and his agents and employees from and
against all claims, damages, losses, and expenses, including reasonable attorneys’ fees arising out of or by reason of complying
with this request.
G) A reproduction of this request by photocopy or similar process shall be for all intents and purposes as valid as the original.
In witness whereof, I have executed this request at ____________________________.
(City)
______________________on the ___________ day of _______________, 20_______.
(State) (Day) (Month) (Year)
____________________________________________
Applicant’s Signature
Subscribed and sworn to before me the ______________ day of
______________________________, 20________.
( MONTH )
__________________________________________________ SEAL
Signature of Notary Public
in and for the County of MARICOPA
State of ARIZONA
My Commission Expires _____________________________
CRA Rev 5/16
Applicant’s Initial__________
14
27.
OATH
A) The undersigned, in connection with the enclosed application for a gaming license, signs this application under oath and
hereby asserts and agrees that:
B) All disclosures stated in the application are full and complete to the best of my knowledge, information and belief. I agree
that a false statement on any part of this application may be grounds for not hiring me, or for firing me after I have begun
work. Additionally, if I am an applicant for a position as a Primary Management Official or Key employee I may be subject
to criminal prosecution under U.S. Code, Title 18, and Section 1001 for any such false statement.
C) The enclosed application shall constitute my agreement that any Tribal or State Investigative agency shall release any
information in its possession concerning me in order to conduct a complete background check and I hereby appoint the
Community Regulatory Agency, as my true and lawful attorney in fact to conduct such background checks as the
Community Regulatory Agency, shall determine in its sole discretion.
D) I also hereby release, acquit and forever discharge the Salt River Pima-Maricopa Indian Community, the Community
Regulatory Agency, Salt River Police Department, and the U. S. Federal Government, and all of its members, agents,
attorneys and employees from all manner of actions, causes of action, suits, debts, judgments, executions, claims and
demands whatsoever, known or unknown, in law of equity, which I ever had, now have, may have, or claim to have
against any or all said entities or individuals arising out of or by reason of the processing or investigation of or other
action relating to the application enclosed herein.
E) The agreements and assertions made are binding on my heirs, executors, administrators, successors and assigns.
Dated this _________ day of __________________________, 20______.
(MONTH )
____________________________________________________
Applicant’s Signature
Subscribed and sworn to before me
________________________________________
(Print Applicant’s Name)
the ________ day of ______________________ 20 ________.
( MONTH )
SEAL
________________________________________
Signature of Notary Public
Notary Public in and for the County of MARICOPA,
State of ARIZONA.
My Commission Expires ______________________.
CRA Rev 5/16
Applicant’s Initial__________
15
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Form 1.: SALT RIVER PIMA-MARICOPA INDIAN COMMUNITY (Salt River Pima-Maricopa Indian Community)

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