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
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