MULTI JURISDICTIONAL PERSONAL HISTORY DISCLOSURE FORM

MULTI JURISDICTIONAL
PERSONAL HISTORY DISCLOSURE FORM
MULTI JURISDICTIONAL
PERSONAL HISTORY DISCLOSURE FORM
This application is designed to allow applicants for casino/gaming qualification to complete one form that is
acceptable to several jurisdictions. The questions contained in this form have been designed to satisfy the variety of
filing and informational requirements of the different jurisdictions that have agreed to accept this form as an
application for qualification.
Each jurisdiction accepting this form may require unique information and documentation that is not
requested in this standardized form. Prior to completing this form, you should contact the appropriate agency in the
jurisdictions where you are seeking qualification, licensure or approval and obtain copies of any documentation or
forms that are supplemental to this standardized form. In addition, copies of this multi jurisdictional form and all
supplemental forms used by the jurisdictions accepting this form may be found on the Internet at www.iagr.org
APPLICATION INSTRUCTIONS
PLEASE READ ALL INSTRUCTIONS CAREFULLY BEFORE COMPLETING THIS FORM.
I.
COMPLETING THIS FORM:
a.
You must make accurate statements and include all material facts. Any misrepresentation, or the
failure to provide requested information, may result in the denial of your application.
b.
Read each question carefully prior to answering. Answer every question completely. Do not leave
blank spaces. If a question does not apply to you, indicate “Does Not Apply” in response to that
question. If there is nothing to disclose in response to a particular question, indicate “None” in
response to that question. Failure to provide a response to every question could result in the
rejection of your application.
c.
All entries on this form, except initials and signatures, must be typed or printed in block lettering
using dark ink. If your application is not legible, it will not be accepted.
d.
You must use blue ink to personally initial, date and identify the gaming agency to which your
application is being submitted in the space provided on the bottom of each page of the form.
e.
If the space available is insufficient to respond to a question, you are to supply the required
information on an attachment page and clearly identify which question you are answering. The
blank page on page 65 may be used to provide this additional information. You must use blue ink
to personally initial, date and identify the gaming agency to which your application is being
submitted at the bottom of each of these attachment pages.
f.
If you make any modification to the pre-printed questions or information contained in this form, your
application will be rejected. Once your application is accepted, it becomes the property of the
gaming agency with which it has been filed and will not be returned.
Initials___________ Gaming Agency__________________________ Date____________________
PHDMJ061901
Page
2
II.
III.
IV.
BE SURE TO:
a.
Attach a recent (within the past six months) color photograph of yourself in the space provided on
page 5.
b.
Sign the Statement of Truth form on page 66 in the presence of a notary public, justice of the
peace, commissioner for declarations or other person legally authorized to notarize your signature.
c.
Check to ensure that you have placed your initials, the date, and identified the gaming agency to
which you are applying, on the bottom of each page of this form in the space provided and on any
attachment pages.
BEFORE YOU SUBMIT THIS FORM TO THE GAMING AGENCY TO WHICH YOU ARE APPLYING,
BE SURE THAT:
a.
You have reviewed the particular gaming agency’s filing instructions for the type of license,
approval or qualification that you are seeking.
b.
You have included all required attachments listed in this form.
c.
The Statement of Truth form is notarized on the original application.
d.
Every question has been answered completely.
e.
You retain a completed copy of your application package for your own records.
f.
You have completed any ancillary forms for the individual jurisdictions.
TIPS FOR COMPLETING THIS FORM:
a. Keep a blank copy of the form. When you need to update information, you can use the appropriate
pages from the blank form to provide the information.
b. Once all questions have been answered, make sufficient copies for all jurisdictions where you will
file your application. Note that you should do this BEFORE the form is signed, dated and notarized.
Since each jurisdiction must receive an application containing original signatures, it is advisable to
make copies before signing the form.
c. Keep an unsigned copy of your completed application. Should you need to file with another
jurisdiction at some point in the future, you can then update the information rather than complete the
form all over again.
d. Be sure to use blue ink where you sign, initial, date and identify the gaming agency where you are
filing your application. Using blue ink will make it clear to the jurisdiction where you are filing that
your application is to be considered an original and not a photocopy.
Initials___________ Gaming Agency__________________________ Date____________________
PHDMJ061901
Page
3
MULTI JURISDICTIONAL
PERSONAL HISTORY DISCLOSURE FORM
PLEASE PRINT OR TYPE THE ANSWERS TO THE
FOLLOWING QUESTIONS IN THE SPACES PROVIDED
PERSONAL DATA
NAME: LAST (INCLUDE SR., JR., ETC., IF APPLICABLE)
FIRST
MIDDLE
MAILING ADDRESS/POSTAL ADDRESS:
NUMBER AND STREET
APT #/FLAT #
CITY/TOWN
STATE/PROVINCE
ZIP/POSTAL CODE
HOME ADDRESS: (IF DIFFERENT THAN MAILING ADDRESS/POSTAL ADDRESS)
NUMBER AND STREET
APT #/FLAT #
CITY/TOWN
STATE/PROVINCE
ZIP/POSTAL CODE
APT #/FLAT #
CITY/TOWN
STATE/PROVINCE
ZIP/POSTAL CODE
PRESENT BUSINESS ADDRESS:
NUMBER AND STREET
HOME TELEPHONE NUMBER:
CURRENT BUSINESS TELEPHONE NO. AT PLACE OF EMPLOYMENT:
FAX NUMBER:
(AREA CODE)
(AREA CODE)
(AREA CODE)
(NUMBER)
(NUMBER)
DATE OF BIRTH: (MO)(DAY)(YEAR)
(EXTENSION)
(NUMBER)
E-MAIL ADDRESS (OPTIONAL):
HAVE YOU BEEN KNOWN BY ANY OTHER NAME OR NAMES? YES
NO
IF YES, LIST THE ADDITIONAL NAMES BELOW AND SPECIFY
DATES OF USE FOR EACH. (INCLUDE MAIDEN NAME, ALIASES, NICKNAMES, OTHER NAME CHANGES, LEGAL OR OTHERWISE.)
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
SEX
COLOR OF EYES
COLOR OF HAIR
HEIGHT
WEIGHT
______FT _____IN/ ______CM
________LBS/ ________KG
DO YOU HAVE ANY SCARS, TATOOS, OR OTHER DISTINGUISHING MARKS AND/OR CHARACTERISTICS? IF SO, PLEASE DESCRIBE.
Initials___________ Gaming Agency__________________________ Date____________________
PHDMJ061901
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4
IMPORTANT
FAILURE TO ANSWER ANY QUESTION ON THIS
FORM COMPLETELY AND TRUTHFULLY WILL
RESULT IN DENIAL OF YOUR APPLICATION.
AFFIX A COLOR PHOTOGRAPH
HERE THAT WAS TAKEN WITHIN
THE PAST SIX MONTHS.
PRINT YOUR NAME ON THE FRONT
BOTTOM BORDER OF THE
PHOTOGRAPH BEFORE
ATTACHING IT.
Initials___________ Gaming Agency__________________________ Date____________________
PHDMJ061901
Page
5
1. Of what country are you a citizen? __________________________________________________________
A. Please indicate:
1. Date of birth: _____________________________________________________________________
DAY
MONTH
YEAR
2. Place of birth: ____________________________________________________________________
CITY/TOWN
STATE/PROVINCE
COUNTRY
3. Country of birth: ___________________________________________________________________
2. Have you ever been issued a passport?
Yes
No
If yes, provide the following information about your passport(s):
PASSPORT NUMBER
Initials___________
PHDMJ061901
COUNTRY OF ISSUE
PLACE ISSUED
Gaming Agency_______________________________________
DATE ISSUED
Date____________________
EXPIRATION DATE
Page
6
RESIDENCE DATA
3. Beginning with your current residence(s) and working backward, provide the following information with respect to each place where you have
lived (including residences while attending college or while in military service) during the past fifteen (15) years or since the age of 18, whichever
is less.
DATES
FROM:
TO:
(MO/YR)
(MO/YR)
Initials___________
PHDMJ061901
ADDRESS
(NO., STREET, APT#/FLAT#, CITY/TOWN, STATE/PROVINCE, COUNTRY & ZIP/POSTAL CODE)
Gaming Agency________________________________________
OWN OR RENT
NAME, ADDRESS & TELEPHONE NO. OF LANDLORD OR
MORTGAGE/BOND HOLDER, IF KNOWN
Date______________________
Page 7
FAMILY/SOCIAL DATA
4. What is your current marital status:
Single
Married
Legally Separated
Divorced
Widow/Widower
Engaged
How many times have you been married? _______
A. CURRENT MARRIAGE
Provide the information below regarding your current marriage and spouse:
Date of Marriage: ________________________________
Where Married: ______________________________________________________________
CITY/TOWN
Name of Spouse: ________________________________________________________
FIRST
MIDDLE
MONTH
COUNTRY
Spouse’s Occupation: _________________________________
Place of Birth: _______________________________________________________________
YEAR
CITY/TOWN
STATE/PROVINCE
Home Address: ____________________________________________________________________
STREET
STATE/PROVINCE
MAIDEN
Date of Birth: ____________________________________
DAY
COUNTY
CITY/TOWN
STATE/PROVINCE
COUNTRY
Telephone Number: _________________________
ZIP/POSTAL CODE
AREA CODE
NUMBER
B. PREVIOUS MARRIAGES
Provide the information below regarding your previous marriages:
(Do NOT include current spouse.)
NAME OF FORMER SPOUSE(S)
(INCLUDE MAIDEN NAME, IF
APPLICABLE)
Initials___________
PHDMJ061901
DATE AND PLACE
OF MARRIAGE
DATE OF
BIRTH
IF ANNULLED, SEPARATED
OR DIVORCED,, INDICATE
DATE AND JURISDICTION
WHERE SUCH ACTION WAS
TAKEN
Gaming Agency________________________________________
DOCKET/CASE #
OF DIVORCE
ACTION (IF
KNOWN)
PRESENT ADDRESSES OF FORMER SPOUSE(S)
(NO., STREET, APT#/FLAT#, CITY/TOWN,
STATE/PROVINCE, COUNTRY,
ZIP/POSTAL CODE)
Date______________________
Page 8
5. a. In the chart below, list the names of all your children, step-children and adopted children and the amount of support, if dependent. Also list all other
persons who you are supporting or contributing to the support of, and provide the amount of support.
NAME
DATE OF BIRTH
BIRTH PLACE
ADDRESS
(NO., STREET, APT., CITY, STATE, COUNTRY, ZIP CODE)
AMT. OF SUPPORT
(IF A DEPENDENT)
5. b. Please mark the appropriate response regarding your child support obligations:
I am not subject to a court order for the support of a child.
I am subject to a court order for the support of one or more children and am in compliance with a plan approved by the public agency/court
enforcing the order for the repayment of the amount owed pursuant to the order (indicate amount in 5a. above); or
I am subject to a court order for the support of one or more children and am NOT in compliance with the order or a plan approved by the public
agency/court enforcing the order for the repayment of the amount owed pursuant to the order.
Identify the public agency/court responsible for enforcing the child support order:
Name _________________________________________________________________________
Address________________________________________________________________________
Contact Person___________________________________________________________________
Initials___________
PHDMJ061901
Gaming Agency________________________________________
Date______________________
Page 9
6.
*
List names, residence addresses, dates of birth, and most recent occupations of parents, parents-in-law, former parents-in-law , or legal
guardians, living or deceased. If retired or deceased, list last address and occupation:
NAME
(INCLUDE MAIDEN)
DATE OF BIRTH
ADDRESS
(NO., STREET, APT#/FLAT#, CITY/TOWN, STATE/PROVINCE, COUNTRY, ZIP/POSTAL CODE)
PHONE NUMBER
OCCUPATION
Father:
Mother:
Father-in-law:
Mother-in-law:
Former Parents-in-law*:
* For former parents-in-law only provide names.
Initials___________
PHDMJ061901
Gaming Agency________________________________________
Date______________________
Page 10
7. List names, dates of birth, home addresses and phone numbers, and the most recent occupations of brothers and sisters and of their respective
spouses:
NAME
(INCLUDE MAIDEN)
DATE OF BIRTH
ADDRESS
(NO., STREET, APT#/FLAT#, CITY/TOWN, STATE/PROVINCE, COUNTRY, ZIP/POSTAL CODE)
PHONE NUMBER
OCCUPATION
Sibling:
Spouse:
Sibling:
Spouse:
Sibling:
Spouse:
Sibling:
Spouse:
Sibling:
Spouse:
Sibling:
Spouse:
Sibling:
Spouse:
Initials___________
PHDMJ061901
Gaming Agency________________________________________
Date______________________
Page 11
MILITARY SERVICE DATA
8. Have you ever served in a military organization of any country or have you been an active or inactive member of a reserve force of any country?
Yes
No
If yes, provide the following information:
Country of Service: __________________________________________________________________________
Branch of Service:______________________________________
Service Serial #: _____________________
Highest Rank Held: ____________________________________
Period(s) of Active Service:
From: _______________________
To:________________________
From: _______________________
To:________________________
9. Date and type of discharge or separation (Honorable, Dishonorable, Honorable Conditions, Medical, etc.) from Military Service(s):
Date of each discharge/separation: ___________________________________________
Type of discharge(s): ______________________________________________________
Attach a copy of your military records* labeled as Exhibit 9M. If unavailable, attach a copy of a letter to the appropriate branch of the military
requesting a copy of your military records* labeled as an Exhibit 9M. If in reserves, please attach a copy of your discharge papers.
10. Have you ever been tried by military court martial or have you had charges** filed against you?
Yes
No
If yes, complete the following chart:
NATURE OF CHARGE
OR ARREST
DATE AND LOCATION OF
CHARGE OR ARREST
NAME OF MILITARY ORGANIZATION
FILING CHARGES
DISPOSITION (CONVICTED,
ACQUITTED, DISMISSED,
PLEADING, ETC.)
SENTENCE
*In the United States, a military record is called a DD214. If you have served in the U.S. military, you should provide a copy of this record. If your military service was in another country, you
should provide a copy of whatever official documentation was provided to you at the time of your discharge.
** Charges filed against you by the military authorities in any country would fall under the Code of Military Justice applicable to that jurisdiction.
In the United States, this means any charges filed against you under Article 15 of the Uniform Code of Military Justice (summary court, deck court, captain’s mast, company punishment, etc.)
Initials___________
PHDMJ061901
Gaming Agency________________________________________
Date______________________
Page 12
EDUCATIONAL DATA
11. Beginning with secondary school (high school), provide the information listed below with respect to each school, college, graduate or post
graduate school you have attended.
DATES
FROM:
(MO/YR)
TO:
(MO/YR)
Initials___________
PHDMJ061901
NAME AND ADDRESS OF SCHOOL,
TRAINING PROGRAM, ETC.
DESCRIPTION OF
EDUCATION PROGRAM
Gaming Agency________________________________________
LIST ANY DEGREE OR
CERTIFICATION
ATTAINED
Date______________________
GRADUATED
YES OR NO
Page 13
OFFICES AND POSITIONS
12. List all offices, trusteeships, directorships or fiduciary positions (including non-profit charitable entities and family trusts) held by you with any
firm, corporation, association, partnership or other business entity during the last ten year period. Begin with the most recent and work
backward.
DATES
FROM:
(MO/YR)
TO:
(MO/YR)
Initials___________
PHDMJ061901
TITLE OF OFFICE OR POSITION HELD
NAME AND ADDRESS OF FIRM, CORPORATION,
ASSOCIATION, PARTNERSHIP OR OTHER BUSINESS ENTITY
Gaming Agency________________________________________
Date______________________
COMPENSATION
RECEIVED
Page 14
12. (Cont.)
DATES
FROM:
(MO/YR)
TO:
(MO/YR)
TITLE OF OFFICE OR POSITION HELD
NAME AND ADDRESS OF FIRM, CORPORATION,
ASSOCIATION, PARTNERSHIP OR OTHER BUSINESS ENTITY
COMPENSATION
RECEIVED
13. List all government positions and offices, whether salaried or unsalaried, held by you during the last ten year period. Begin with the most recent
and work backward.
DATES
FROM:
(MO/YR)
TO:
(MO/YR)
Initials___________
PHDMJ061901
TITLE OF OFFICE OR POSITION HELD
Gaming Agency________________________________________
NAME AND ADDRESS OF
GOVERNMENT AGENCY/ORGANIZATION
Date______________________
Page 15
EMPLOYMENT AND LICENSING DATA
*
14. Have you ever been employed by a casino or gaming/gambling related company in any jurisdiction?
Yes
No
*Casino or gaming/gambling related company includes any form or type of casino, gaming/gambling related operation, any manufacturer of
gaming/gambling equipment, junket enterprise, horse racing, dog racing, pari-mutuel operation, lottery, sports betting, Internet gaming, etc.
NAME OF GAMING/GAMBLING
GAMING RELATED COMPANY
AND COUNTRY/STATE WHERE
YOU WERE EMPLOYED
Initials___________
PHDMJ061901
NAME, MAILING
ADDRESS AND
TELEPHONE NUMER OF
EMPLOYER(S)
DATES
FROM
(MO/YR)
TO
(MO/YR)
TITLE/POSITION HELD AND
DESCRIPTION OF DUTIES
Gaming Agency________________________________________
NAME OF SUPERVISOR
Date______________________
REASON FOR LEAVING
Page 16
15. In the chart below, provide the information regarding your employment for the past twenty years or from age 18, whichever is less. Begin with
your present job and work backwards. Give dates of any unemployment between jobs in proper sequence. Include all part-time and full-time
employment and any military service. For any casino or gaming/gambling related employment identified in the previous question, you are only
required to fill in the dates of employment and the name of the casino or gaming/gambling related company on this chart.
DATES
FROM:
(MO/YR)
TO:
(MO/YR)
Initials___________
PHDMJ061901
NAME, MAILING ADDRESS, AND
TELEPHONE NUMBER OF EMPLOYER(S)
TITLE/POSITION HELD AND
DESCRIPTION OF DUTIES
Gaming Agency________________________________________
NAME OF
SUPERVISOR
Date______________________
REASON FOR LEAVING/
COMPENSATION AT DEPARTURE
Page 17
15. (Cont.)
DATES
FROM:
(MO/YR)
TO:
(MO/YR)
NAME, MAILING ADDRESS, AND
TELEPHONE NUMBER OF EMPLOYER(S)
TITLE/POSITION HELD AND
DESCRIPTION OF DUTIES
NAME OF
SUPERVISOR
REASON FOR LEAVING/
COMPENSATION AT DEPARTURE
If additional space is needed, please provide an attachment.
Initials___________
PHDMJ061901
Gaming Agency________________________________________
Date______________________
Page 18
16. With regard to the previously listed employment:
a. Were you ever discharged, suspended or asked to resign from employment?
b. During the last ten year period, were you ever charged with any infraction
in relation to any employment which was the subject of any disciplinary action?
Yes
No
Yes
No
If yes to either question, complete the following chart as to each such time you were discharged, suspended, asked to resign or disciplined:
DATE OF DISCHARGE,
SUSPENSION, RESIGNATION
OR DISCIPLINARY ACTION
Initials___________
PHDMJ061901
NAME AND ADDRESS OF EMPLOYER
Gaming Agency________________________________________
NAME OF
SUPERVISOR
REASON FOR DISCHARGE, SUSPENSION,
RESIGNATION OR DISCIPLINARY ACTION
Date______________________
Page 19
17. List any and all compensated employment, of whatever nature, held by your spouse during the past twelve month period. Begin with your
spouse’s current employer.
DATES
FROM:
(MO/YR)
TO:
(MO/YR)
NAME, ADDRESS AND TELEPHONE NUMBER OF EMPLOYER
TITLE/
POSITION HELD
18. To the best of your knowledge, have you or has your spouse served as a trustee or other fiduciary officer in any capacity during the last twelve
month period?
Yes
No
If yes, complete the following chart:
DATES
FROM:
(MO/YR)
TO:
(MO/YR)
Initials___________
PHDMJ061901
CAPACITY
NATURE OF TRUST
OR OTHER FUND
Gaming Agency________________________________________
INCOME RECEIVED
Date______________________
FOR WHOM HELD
Page 20
19. a. Have you or your spouse ever sought and been denied a position as a trustee or other fiduciary officer?
b. Have you or your spouse ever been suspended or removed from a position as a trustee or other fiduciary officer?
Yes
No
Yes
No
If yes to either question, complete the following chart:
DATE
CAPACITY
NATURE OF TRUST OR OTHER OFFICE
REASON FOR DENIAL, SUSPENSION
OR REMOVAL
20. Have you or has your spouse ever made application for, or held, any NON-GAMING professional or occupational license, permit or certification,
in any jurisdiction, including but not limited to the following: real estate broker or salesman, accountant, attorney, medical, boxing promoter,
manager or matchmaker, race horse owner, trainer or manager, jockey, race dog owner, securities dealer, contractor, pilot, insurance, or any
other type of professional license. (Do not include alcoholic beverage or driver’s license). You must answer “YES” to this question if you ever
applied and your application was granted, denied, returned to you by the licensing agency for any reason, withdrawn or is currently pending.
Yes
No
If yes, complete the following chart:
DATES
NAME ON LICENSE
Initials___________
PHDMJ061901
TYPE OF LICENSE
FROM:
(MO/YR)
TO:
(MO/YR)
Gaming Agency________________________________________
NAME AND ADDRESS
OF LICENSING AGENCY/ORGANIZATION
Date______________________
DISPOSITION OF
THE APPLICATION
Page 21
21. Have any of the licenses, permits or certifications applied for, or held by you or your spouse, as identified in the previous question ever been
denied, suspended, revoked or subject to any conditions in any jurisdiction?
No
Yes
If yes, complete the following chart as to each denial, suspension, revocation or conditions:
TYPE OF LICENSE,
PERMIT OR CERTIFICATE
NAME & ADDRESS OF
GOVERNMENTAL AGENCY/ORGANIZATION
DATE OF DENIAL,
SUSPENSION. REVOCATION
OR CONDITION
REASON(S) FOR DENIAL
SUSPENSION OR REVOCATION
22. Has any entity in which you, or your spouse, is/was a director, officer, partner or an owner of a 5% or greater interest ever had any license,
permit or certificate issued by a governmental agency in any jurisdiction denied, suspended, revoked, or subject to any conditions?
No
Yes
If yes, complete the following chart as to each denial, suspension or revocation:
NAME OF ENTITY
Initials___________
PHDMJ061901
POSITION HELD BY
YOU OR YOUR SPOUSE
TYPE OF
LICENSE,
PERMIT OR
CERTIFICATE
TYPE OF
ACTION TAKEN
Gaming Agency________________________________________
NAME AND ADDRESS OF
GOVERNMENT
AGENCY/ORGANIZATION TAKING
ACTION
Date______________________
DATE OF
ACTION
REASON(S)
FOR
ACTION
Page 22
23. List any group, firm, partnership, corporation or any other businesses in which you have held an ownership interest of 5% or more for the past
twenty years, or since the age of 18, whichever is less. (Do not include publicly traded corporations in which you owned stock.)
DATES
FROM:
(MO/YR)
TO:
(MO/YR)
Initials___________
PHDMJ061901
NAME(S) & ADDRESS(ES)
OF BUSINESS(ES)
CURRENT STATUS
OF BUSINESS(ES)
% INTEREST
HELD BY
YOU
Gaming Agency________________________________________
NAME(S) OF
OTHER OWNERS
ADDRESS(ES)
OF OTHER OWNERS
Date______________________
STATE/PROVINCE
AND COUNTRY OF
ORGANIZATION OR
INCORPORATION
Page 23
24. Have you or has your spouse ever made application for, or held, a license, permit, registration, finding of suitability, qualification or other
authorization to participate in any form or type of casino, gaming/gambling related operation (including any manufacturer of gaming/gambling
equipment, junket operation, horse racing, dog racing, pari-mutuel operation, lottery, sports betting, Internet gaming, etc.) or alcoholic beverage
operation in any jurisdiction? You must answer “YES” to this question if you ever applied and your application was granted, denied, returned to
you by the gaming agency for any reason, withdrawn or is currently pending.
Yes
No
If yes, complete the following chart:
NAME & ADDRESS OF LICENSING AGENCY/ORGANIZATION
(INCLUDING COUNTRY, STATE/PROVINCE, COUNTY
OR MUNICIPALITY/TOWN)
Initials___________
PHDMJ061901
TYPE OF LICENSE,
PERMIT, APPROVAL
OR REGISTRATION
Gaming Agency________________________________________
DATE OF
APPLICATION
DISPOSITION
(GRANTED, DENIED
OR PENDING, ETC.)
Date______________________
LICENSE, PERMIT,
APPROVAL OR
REGISTRATION
NUMBER
Page 24
25. For each casino, gaming/gambling related or alcoholic beverage operation application, license, permit, registration, finding of suitability,
qualification or other authorization identified in the previous question, were you or your spouse ever called to appear to testify, or otherwise
participate in a hearing or proceeding, before the licensing agency or commission to which you were applying?
No
Yes
If yes, complete the following chart:
NAME AND ADDRESS OF LICENSING AGENCY OR COMMISSION
Initials___________
PHDMJ061901
DATE OF APPEARANCE(S)
Gaming Agency________________________________________
NATURE OF HEARING
Date______________________
WAS TESTIMONY GIVEN?
Page 25
26. To the best of your knowledge, in the past twenty years or since the age of 18, whichever is less, have you held a direct or indirect financial or
ownership interest in any group, firm, corporation, partnership or other business entity that has applied to any licensing agency in any jurisdiction
for any license, permit, registration, finding of suitability, or qualification in connection with any form or type of a casino, gaming/gambling related
operation (including any manufacturer of gaming/gambling equipment, junket operation, horse racing, dog racing, pari-mutuel operation, lottery,
sports betting, Internet gaming, etc.), or alcoholic beverage operation? (Do not include publicly traded corporations or entities in which you held
less than 1% of the stock.)
No
Yes
If yes, complete the following chart:
NAME AND ADDRESS
OF BUSINESS ENTITY
Initials___________
PHDMJ061901
NATURE OF
YOUR INTEREST
DATE OF
APPLICATION
NAME & ADDRESS OF LICENSING
AGENCY
TO WHICH APPLICATION WAS MADE
Gaming Agency________________________________________
TYPE OF LICENSE
APPLIED FOR
Date______________________
DISPOSITION OF
APPLICATION
Page 26
27. a. Are any members of your family (spouse, parents, grandparents, children, grandchildren, siblings, uncles, aunts, nephews, nieces, fathers-inlaw, mothers-in-law, sons-in-law, daughters-in-law, brothers-in-law and sisters-in-law whether by whole or half blood, by marriage, adoption
or natural relationship) associated with or employed in any form or type of casino or gaming/gambling related operation as defined in
question 26 in any jurisdiction?
No
Yes
b. Do you or any members of your family (spouse, parents, grandparents, children, grandchildren, siblings, uncles, aunts, nephews, nieces,
fathers-in-law, mothers-in-law, sons-in-law, daughters-in-law, brothers-in-law and sisters-in-law whether by whole or half blood, by marriage,
adoption or natural relationship) have an ownership interest in any alcoholic beverage entity in any jurisdiction?
No
Yes
If yes to either question, complete the following chart:
NAME OF PERSON
Initials___________
PHDMJ061901
RELATIONSHIP
NAME OF GAMING/GAMBLING OR ALCOHOLIC BEVERAGE BUSINESS
AND ADDRESS
Gaming Agency________________________________________
Date______________________
BUSINESS TELEPHONE
Page 27
CIVIL, CRIMINAL AND INVESTIGATORY PROCEEDINGS
The next question asks about any arrests, charges or offenses you, your spouse or your children may have committed. Prior to answering this
question, carefully review the definitions and instructions which follow.
DEFINITIONS:
For purposes of this question:
A. “Arrest” includes any detaining, holding, or taking into custody by any police or other law enforcement authorities to
answer for the alleged performance of any “offense.”
B. “Charge” includes any indictment, complaint, information, summons, or other notice of the alleged commission of any
“offense.”
C. “Offense” includes all felonies, crimes, high misdemeanors, misdemeanors, disorderly persons offenses, petty disorderly
offenses, driving while intoxicated/impaired motor vehicle offenses and violations of probation or any other court order.
Juvenile offenses that occurred within the most recent 10 year period are also included within the definition of “offenses.”
INSTRUCTIONS:
1. Answer “YES” and provide all information to the best of your ability EVEN IF:
A. You did not commit the offense charged;
B. The charges were dismissed or subsequently downgraded to a lesser charge;
C. You completed a Pretrial Intervention (PTI) or equivalent diversionary program in other jurisdictions;
D. You were not convicted;
E. You did not serve any time in prison or jail; or
F. The charges or offenses happened a long time ago.
2. Answer “NO” IF any records relating to a charge, an arrest or conviction have been expunged or otherwise officially sealed by a
*
court or government agency .
* Some jurisdictions permit the gaming agency to obtain information about the expungement or sealing order as part of the licensing
process. You should confer with the gaming agency to which you are applying to determine the applicable law.
IMPORTANT
The gaming agency will make inquiries to establish whether the applicant
has had any involvement with law enforcement agencies.
Failure to disclose any such involvement will be taken into account in
assessing your character, honesty and integrity.
Initials___________
PHDMJ061901
Gaming Agency________________________________________
Date______________________
Page 28
28. Have you ever been arrested or charged with any crime or offense in any jurisdiction?
Yes
No
If yes, complete the following chart:
NATURE OF CHARGE OR OFFENSE/
LOCATION OF WHERE INCIDENT OCCURRED
Initials___________
PHDMJ061901
DATE OF CHARGE OR
OFFENSE
NAME AND ADDRESS
OF LAW ENFORCEMENT AGENCY
OR COURT INVOLVED
Gaming Agency________________________________________
DISPOSITION
(CONVICTED, ACQUITTED,
DISMISSED, PENDING,
PARDONED, ETC.)
Date______________________
SENTENCE
Page 29
29. To the best of your knowledge, has a criminal indictment, information or complaint ever been filed or returned against you, but for which you
were not arrested or in which you were named as an unindicted party or unindicted co-conspirator in any criminal proceeding in any jurisdiction?
Yes
No
If yes, complete the following chart:
NAME AND ADDRESS OF
GOVERNMENTAL AGENCY/ORGANIZATION INVOLVED
NATURE OF PROCEEDING
DATE
30. Have you ever been the subject of an investigation conducted by any governmental agency/organization, court, commission, committee, grand
jury or investigatory body (local, state, county, provincial, federal, national, etc.) other than in response to a traffic summons?
No
Yes
If yes, complete the following chart:
NAME AND ADDRESS OF
COURT OR OTHER AGENCY
Initials___________
PHDMJ061901
NATURE OF PROCEEDING
OR INVESTIGATION
Gaming Agency________________________________________
WAS TESTIMONY
GIVEN?
DATE ON WHICH
TESTIMONY
WAS GIVEN
Date______________________
APPROXIMATE
TIME PERIOD OF
INVESTIGATION
Page 30
31. a. Have you ever been called to testify before, or otherwise been questioned, interviewed, deposed, or requested to take a polygraph exam by any
governmental agency/organization, court, commission, committee, grand jury or investigative body (local, state, county, provincial, federal, national,
etc.) in any jurisdiction other than in response to a traffic summons?
Yes
No
b. Have you ever been subpoenaed to appear or testify before a federal, national, state, county grand jury, or other criminal investigatory agency or
body, or any board or commission, or any civil, criminal or administrative proceeding or hearing?
No
Yes
If yes to either question, complete the following chart:
NAME AND ADDRESS OF
COURT OR OTHER AGENCY/ORGANIZATION
NATURE OF PROCEEDING
OR INVESTIGATION
WAS TESTIMONY
GIVEN?
DATE ON WHICH
TESTIMONY
WAS GIVEN
APPROXIMATE
TIME PERIOD OF
INVESTIGATION
32. Have you ever received a pardon, or has any government agency/organization agreed to dismiss, suspend or defer any criminal investigation or
prosecution against you for any criminal offense?
No
Yes
If yes, complete the following chart:
DATE OF PARDON,
DISMISSAL, SUSPENSION,
OR DEFERAL
Initials___________
PHDMJ061901
TYPE OF ACTION TAKEN
NAME AND ADDRSS OF GOVERNMENT AGENCY/ORGANIZATION GRANTING PARDON, DISMISSAL
SUSPENSION OR DEFERAL
Gaming Agency________________________________________
Date______________________
Page 31
33. Has your spouse or any of your children, step-children or adopted children ever been arrested or charged with any crime or offense (as defined
at the beginning of this section) in any jurisdiction?
No
Yes
If yes, complete the following chart:
NAME OF PERSON
Initials___________
PHDMJ061901
RELATIONSHIP
NATURE OF
CHARGE OR
OFFENSE
DATE OF
CHARGE OR
OFFENSE
NAME & ADDRESS OF LAW
ENFORCEMENT AGENCY
OR COURT INVOLVED
Gaming Agency________________________________________
DISPOSITION
(CONVICTED, ACQUITTED,
DISMISSED, PENDING,
PARDONED, ETC.)
Date______________________
SENTENCE
Page 32
34. In the past fifteen (15) years, have you as an individual, member of a partnership, or owner, director, or officer of a corporation, ever been a
party to a lawsuit, as either a plaintiff or defendant or an arbitration as either a claimant or defendant? (Include matrimonial matters, negligence
matters, auto accident matters, contract matters, collection matters, debt matters, bankruptcies, etc.)
No
Yes
If yes, complete the following chart:
DATE
FILED
Initials___________
PHDMJ061901
NAME & ADDRESS
OF COURT
DOCKET/CASE
NUMBER
OTHER PARTIES TO SUIT
Gaming Agency________________________________________
NATURE OF SUIT
DISPOSITION
Date______________________
DATE OF
DISPOSITION
Page 33
35. In the past fifteen (15) years, has any general partnership, business venture, sole proprietorship or closely held corporation, which you were
associated with as an owner, officer, director or partner, been a party to a lawsuit, arbitration or bankruptcy?
Yes
No
If yes, complete the following chart:
NAME OF ENTITY
Initials___________
PHDMJ061901
TYPE OF ENTITY
APPROXIMATE DATE(S) OF
LAWSUIT/ARBITRATION/BANKRUPTCY
Gaming Agency________________________________________
Date______________________
WHERE ACTION FILED
(CITY/TOWN, STATE/PROVINCE,
COUNTY)
Page 34
36. In the past ten years, have you been cited or charged with, or formally accused of, any violation of a statute, regulation or code of any local,
state, county, municipal, provincial, federal or national government other than a criminal, disorderly persons, petty disorderly person or motor
vehicle violation?
Yes
If yes, complete the following chart:
GOVERNMENTAL AGENCY/ORGANIZATION
Initials___________
PHDMJ061901
NATURE OF CHARGE
Gaming Agency________________________________________
DATE
Date______________________
DISPOSITION
Page 35
No
37. Have you ever been barred or otherwise excluded, for any reason, other than for the denial, suspension or revocation of a license or
registration, from any form or type of casino or gaming/gambling related operation in any jurisdiction? (Check “YES” even if the disbarment or
exclusion is no longer in effect or has been lifted.)
Yes
No
If yes, complete the following chart:
GAMING/GAMBLING AGENCY
DATE OF EXCLUSION
REASON FOR EXCLUSION
VEHICLE OPERATOR DATA
38. In the chart below, list all current motor vehicle operator licenses (automobiles, motorcycles, airplanes, boats, recreational vehicles, etc.) issued
to you in any jurisdiction:
DATE LAST
ISSUED
Initials___________
PHDMJ061901
LICENSE NUMBER
TYPE OF LICENSE
Gaming Agency________________________________________
JURISDICTION ISSUING LICENSE
Date______________________
EXPIRATION DATE
OF LICENSE
Page 36
FINANCIAL DATA
39. Have any individual, local, city, county, provincial, state, Federal, national, or any other governmental liens/debts been filed against you as an
individual, sole proprietor, member of a partnership, or owner of a corporation in any jurisdiction?
No
Yes
If yes, complete the following chart:
NATURE OF LIEN/DEBT
Initials___________
PHDMJ061901
WHEN FILED
Gaming Agency________________________________________
WHERE FILED
Date______________________
CURRENT STATUS
Page 37
40. Have you personally ever been adjudicated bankrupt or filed a petition for any type of bankruptcy, insolvency or liquidation under any bankruptcy
or insolvency law in any jurisdiction?
Yes
No
If yes, complete the following chart:
DATE FILED
DOCKET/CASE NUMBER
NAME AND ADDRESS OF COURT
NAME AND ADDRESS OF TRUSTEE
41. In the past twenty years or since the age of 18, whichever is less, has any business entity in which you held a 5% or greater ownership interest,
or in which you served as an officer or director been adjudicated bankrupt or filed a petition for any type of bankruptcy or insolvency under any
bankruptcy or insolvency law?
No
Yes
If yes, complete the following chart:
DATE
FILED
Initials___________
PHDMJ061901
DOCKET/CASE
NUMBER
NAME AND ADDRESS OF COURT
NAME AND ADDRESS OF FILING PARTY
Gaming Agency________________________________________
Date______________________
NAME AND ADDRESS OF TRUSTEE
Page 38
42. Have you as an individual, member of a partnership, or owner, director or officer of a corporation ever been in a business entity that has been in
liquidation, receivership or been placed under some form of governmental administration or monitoring?
No
Yes
If yes, complete the following chart:
NAME AND ADDRESS OF BUSINESS
ENTITY
YOUR RELATIONSHIP TO
BUSINESS ENTITY
DATE PLACED
UNDER
LIQUIDATION,
RECEIVERSHIP,
ETC.
REASON PLACED UNDER LIQUIDATION,
RECEIVERSHIP, ETC.
PRESENT STATUS
43. Have your wages, earnings, or other income been subject to garnishment, attachment, charging order, voluntary wage execution or the like
during the past ten year period?
No
Yes
If yes, complete the following chart:
DATE
FILED
Initials___________
PHDMJ061901
DOCKET/CASE
NUMBER
NAME AND ADDRESS OF COURT
NATURE OF
OBLIGATION
Gaming Agency________________________________________
AMOUNT OF
OBLIGATION
Date______________________
NAME AND ADDRESS OF
HOLDER OF OBLIGATION
Page 39
44. In the past ten years, have you ever had any property, real or personal, repossessed by a finance company in any jurisdiction?
Yes
No
If yes, complete the following chart:
TYPE OF PROPERTY
DATE REPOSSESSED
NAME AND ADDRESS OF COMPANY
REPOSSESSING PROPERTY
REASON FOR REPOSSESSION
45. During the last ten year period, have you been:
a. An executor(trix), administrator or other fiduciary of any estate;
b. A beneficiary or legatee under a will or received any thing of value under an intestacy statute; or
c. A settlor/grantor, beneficiary or trustee of any trust?
Yes
No
If yes, complete the following chart as to each estate and trust:
NAME AND LOCATION
OF ESTATE/TRUST
Initials___________
PHDMJ061901
POSITION/ INTEREST HELD
Gaming Agency________________________________________
DATE(S) ON WHICH
POSITIONS
WERE HELD OR INTEREST
WAS RECEIVED
Date______________________
AMOUNT OF COMPENSATION OR
NATURE AND VALUE OF
BENEFIT GRANTED/RECEIVED
Page 40
46. Do you own, hold, or have an interest in any assets in a trust in any jurisdiction? (You may exclude those assets disclosed in your answer to
question 45).
No
Yes
If yes, complete the following chart:
DESCRIPTION OF TRUST
LOCATION OF TRUST
NAME OF TRUSTEE(S)
NAMES OF OTHER(S) WITH INTERESTS IN TRUST
47. Do you hold, manage or control in trust, or otherwise, any assets or liabilities for another person or entity in any jurisdiction? (You may exclude
those assets or liabilities disclosed in your answer to question 45).
Yes
No
If yes, complete the following chart:
DESCRIPTION OF TRUST
Initials___________
PHDMJ061901
LOCATION OF TRUST
Gaming Agency________________________________________
NAMES OF OTHER(S) WITH INTEREST IN TRUST
Date______________________
Page 41
48. a. Please state your country of residence _____________________________________
b. During the last ten year period have you had any right of ownership in, control over or interest in any bank account(s), which are located
outside the country of residence identified in a. above?
Yes
No
If yes, complete the following chart:
DATES
FROM:
(MO/YR)
TO:
(MO/YR)
Initials___________
PHDMJ061901
NAME AND ADDRESS OF
INSTITUTION HOLDING ACCOUNT
ACCOUNT NUMBER
Gaming Agency________________________________________
NAME AND ADDRESS OF
EACH PERSON/ENTITY APPEARING
ON THE ACCOUNT
Date______________________
PRESENT AMOUNT HELD/
AMOUNT HELD BEFORE
CLOSING
Page 42
c. Do you own, manage or control any assets, or are you responsible for any liabilities, located outside the country of residence as identified in
a. above (excluding any foreign bank accounts identified in b. above)?
No
Yes
If yes, complete the following chart:
DESCRIPTION OF ASSET/LIABIITY
LOCATION OF ASSET/LIABILITY
49. During the last ten year period, have you or has your spouse or any of your children, while dependent, received a loan in excess of $25,000USD?
(If you are applying in a jurisdiction other than the United States, the amount you are required to report is the equivalent to $25,000USD in the national currency of the jurisdiction where you will be
filing this application.)
Yes
No
If yes, complete the following chart:
DATE
RECEIVED
LOAN
Initials___________
PHDMJ061901
NAME AND ADDRESS
OF LENDER
NAME OF BORROWER
AND ALL CO-SIGNERS
Gaming Agency________________________________________
ORIGINAL
AMOUNT
OF LOAN
Date______________________
INTEREST
RATE
(%)
TERMINATION
DATE
OF LOAN
Page 43
50. During the last ten year period, have you or has your spouse or any of your children, while dependent, made any loan in excess of $10,000USD?
(If you are applying in a jurisdiction other than the United States, the amount you are required to report is the equivalent of $10,000USD in the national currency of the jurisdiction where you will be
filing this application.)
Yes
No
If yes, complete the following chart:
DATE
OF LOAN
NAME AND ADDRESS
OF BORROWER
ALL CO-PARTIES
TO LOAN
NAME OF LENDER
ORIGINAL
AMOUNT
OF LOAN
INTEREST
RATE
(%)
SECURITY
PLEDGED
TERMINATION
DATE
OF LOAN
51. Have you individually ever exchanged currency in an amount of more than $10,000USD within the past ten years? (If you are applying in a jurisdiction
other than the United States, the amount you are required to report is the equivalent of $10,000USD in the national currency of the jurisdiction where you will be filing this application.)
Yes
No
If yes, complete the following chart:
DATE AND AMOUNT OF EXCHANGE
Initials___________
PHDMJ061901
LOCATION WHERE EXCHANGE MADE
REASON FOR EXCHANGE
Gaming Agency________________________________________
DID YOU FILL OUT OR FILE ANY
GOVERNMENTAL REPORTING DOCUMENT
Date______________________
Page 44
52. Do you maintain a brokerage or margin account with any securities or commodities dealer?
Yes
No
If yes, complete the following chart:
TYPE OF ACCOUNT
NAME AND ADDRESS OF DEALER
AMOUNT OF MARGIN
53. Have you or has your spouse or children, while dependent, filed any claims in excess of $100,000USD under any fire, theft, automobile or
insurance policy within the past ten year period? (If you are applying in a jurisdiction other than the United States, the amount you are required to report is the equivalent of
$100,000USD in the national currency of the jurisdiction where you will be filing this application.)
Yes
No
If yes, complete the following chart:
DATE
OF CLAIM
Initials___________
PHDMJ061901
NATURE OF CLAIM
Gaming Agency________________________________________
NAME AND ADDRESS OF
INSURANCE CARRIER
Date______________________
DISPOSITION
Page 45
54. During the last five year period, have you, your spouse or dependent children given or received any gift or gifts, whether tangible or intangible
which either individually or in the aggregate exceeded $10,000USD in value in any one year period? (If you are applying in a jurisdiction other than the United States,
the amount you are required to report is the equivalent of $10,000USD in the national currency of the jurisdiction where you will be filing this application.)
Yes
No
If yes, complete the following chart as to each gift:
NAME OF THE
DONOR OR DONEE
DATE GIFT
GIVEN/RECEIVED
DESCRIPTION OF GIFT
55. a. Do you have any safe deposit boxes in your name in any jurisdiction?
b. Do you have access to the funds in any other safe deposit boxes in any jurisdiction?
APPROXIMATE
VALUE
Yes
No
Yes
No
If yes to either question, complete the following chart:
NAME AND ADDRESS OF BANK OR OTHER
INSTITUTION/BUSINESS WHERE LOCATED
Initials___________
PHDMJ061901
NAME(S) IN WHICH ACCOUNT(S)
OR SAFE DEPOSIT BOX(ES) HELD
Gaming Agency________________________________________
TYPE OF ACCOUNT,
(SAVINGS, CHECKING,
SAFE DEPOSIT, ETC.)
Date______________________
ACCOUNT NO. OR
SAFE DEPOSIT BOX NO.
Page 46
56. In the past ten years, or since the age of 18, whichever is less, have you received any referral or finder’s fee in excess of $10,000USD
(If you are applying in a jurisdiction other than the United States, the amount you are required to report is the equivalent of $10,000USD. In the national currency of the jurisdiction where
you will be filing this application.)
Yes
No
If yes, complete the following chart:
NAME AND ADDRESS
OF ALL PARTIES INVOLVED
NATURE OF GOODS OR
SERVICES PROVIDED
AMOUNT RECEIVED
DATE RECEIVED
57. Have you, in the past ten years or since the age of 18, whichever is less, given a guarantee, co-signed or otherwise insured payment of a loan,
debt or other financial obligation in any jurisdiction?
No
Yes
If yes, complete the following chart:
NATURE OF OBLIGATION
(PERSONAL GUARANTEE, ETC.)
Initials___________
PHDMJ061901
DATE OBLIGATION MADE
NAME(S) OF PERSON RESPONSIBLE FOR
OBLIGATION
Gaming Agency________________________________________
Date______________________
STATUS OF UNDERLYING OBLIGATION
Page 47
NET WORTH STATEMENT -- ASSETS AND LIABILITIES
NOTE: Complete the financial statements on pages 49 through 63 and copy the totals in the appropriate space below.
58. Please list all assets, tangible and intangible, in which a direct or indirect interest is held by you,
59. Please list all liabilities of you, your spouse and your dependent children.
your spouse or your dependent children. For each line item, list both the cost of the asset and the
Enter the amount as of the date of this statement. Detail each line entry
present market values as of the date of this statement unless this cannot reasonably be done, in
on the appropriate schedule.
which case any special valuation date should be noted in the column provided. Detail each line
LIABILITY
entry on the appropriate schedule.
ASSET
1. Cash
a) On Hand
b) In bank (Schedule A)
2. Loans, Notes and
Other Receivables
COST AT DATE
ACQUIRED OR
PURCHASED
(A)
CURRENT
MARKET
VALUE
(B)
a)
b)
SPECIAL
VALUATION
DATE, IF ANY
b)
(Schedule B)
ORIGINAL AMOUNT
AMOUNT
OF LIABILITY
OUTSTANDING
(C)
(D)
10. Notes Payable
(Schedule I)
11. Loans and Other
Payables
(Schedule J)
12. Taxes Payable
(Schedule K)
13. Mortgages or Liens on
Real Estate
3. Securities
(Schedule L)
(Schedule C)
4. Real Estate Interests
(Schedule D)
14. Loans Against
Insurance/Pensions
(Schedule M)
5. Cash Value Life Insurance
(Schedule E)
6. Cash Value Pension/
15. Other Indebtedness
(Schedule N)
TOTAL LIABILITIES
Retirement Funds
(Schedule F)
7. Furniture and Clothing
(Reasonable Estimate)
8. Vehicles
NET WORTH
Total Assets
(From Column B) less
Total Liabilities
(From Column D)
(Schedule G)
16. Contingent Liabilities
9. Other
(Schedule H)
(Schedule O)
Date of Statement ________________________________________________________
TOTAL ASSETS
Please provide the name, address and phone number of the person
completing this statement if it is completed by someone other than you.
Name ___________________________________________________________
Address _________________________________________________________
Phone __________________________________________________________
Initials___________
PHDMJ061901
Gaming Agency________________________________________
Date______________________
Page 48
SCHEDULE “A” - CASH IN BANK
60. List below all bank accounts (checking, savings, time deposits, certificates of deposit, money market funds, etc.) foreign and domestic,
maintained by you, your spouse or dependent children. Identify with an asterisk (*) any check writing accounts held with brokerage houses,
insurance companies, etc.
NAME AND ADDRESS
OF INSTITUTION
NAME OF PERSON(S) AND
TAX IDENTIFICATION NUMBER(S)
APPEARING ON ACCOUNT
ACCOUNT
NUMBER
INTEREST
RATE
(%)
GENERAL NATURE
OF ACCOUNT
DATE OF
BALANCE
BALANCE
$ _________________
TOTAL CURRENT
BALANCE
(Enter this figure
in item 1b,
column B
on page 48.)
Initials___________
PHDMJ061901
Gaming Agency________________________________________
Date______________________
Page 49
SCHEDULE “B” – LOANS, NOTES AND OTHER RECEIVABLES
Initials___________
PHDMJ061901
NAME AND ADDRESS
OF DEBTOR
INTEREST
RATE
(%)
ORIGINAL
LOAN
AMOUNT
TOTAL
PAY-MENTS
CHECK IF
HELD BY
SPOUSE
OR
DEPENDENT
CHILD
ORIGINAL
DATE OF
LOAN/NOTE
RECEIVABLE
61. List below all loans, notes and other receivables held by you, your spouse or dependent children.
DATE
DUE
NATURE OF
ADVANCE AND
NATURE OF
SECURITY, IF ANY
(INDICATE IF
UNSECURED)
CURRENT
BALANCE
$_______________
$________________
TOTAL ORIGINAL
LOAN AMOUNT(S)
(Enter this figure in
items 2, column A
on page 48.)
TOTAL CURRENT
BALANCE
(Enter this figure in
items 2, column B on
page 48.)
Gaming Agency________________________________________
Date______________________
Page 50
SCHEDULE “C” - SECURITIES
NUMBER OF
SECURITIES
OR
CONTRACTS
HELD
Initials___________
PHDMJ061901
TYPE OF
SECURITY
NAME OF
ISSUING
COMPANY OR GOVERNMENT
AGENCY/ORGANIZATION
DATE OF
AND PRICE
AT PURCHASE
% OF
OWNERSHIP
IF GREATER
THAN 5%
CHECK IF
HELD BY
SPOUSE
OR
DEPENDENT
CHILD
MARKET
VALUE AT
TIME OF
ACQUISITION
62. Provide the information in the table below for all stocks, bonds, mutual funds, commodity accounts, options, warrants, etc., held or controlled by
you, your spouse or dependent children in any jurisdiction. Whenever interest exists through a mutual fund or holding company, the individual
stocks or bonds held by such mutual fund or holding company need not be listed; whenever such interest exists through a beneficial interest in a
trust, the securities held in such trust shall be listed if you, your spouse or dependent children have knowledge of what securities are so held.
INDICATE PUBLICLY TRADED SECURITIES BY AN ASTERISK( * ).
REGISTERED
OWNER
DATE
OF
VALUATION
CURRENT
MARKET
VALUE
$_______________
$_______________
TOTAL
PURCHASE
PRICE
(Enter this figure in
item 3, column A
on page 48.)
TOTAL CURRENT
MARKET VALUE
(Enter this figure in
item 3, column B
on page 48.)
Gaming Agency________________________________________
Date______________________
Page 51
SCHEDULE “D” - REAL ESTATE INTERESTS
63. Indicate below the location, size, general nature, acquisition date and other information requested regarding any real property in any jurisdiction
in which any direct, indirect, vested or contingent interest is held by you, your spouse or dependent children, along with the names of all
individuals or entities who share a direct, indirect, vested or contingent interest therein.
CHECK
IF HELD BY
SPOUSE
OR
DEPENDENT
CHILD
ADDRESS
PARCEL/LOT
NUMBER
Initials___________
PHDMJ061901
LOT SIZE/
STAND NO./
SQUARE
FOOTAGE
OF BUILDING
TYPE OF
PROPERTY
DATE
ACQUIRED/
DOWN
PAYMENT
INDIVIDUALS OR
ENTITIES SHARING
INTEREST
(INCLUDE % OF
OWNERSHIP FOR EACH)
Gaming Agency________________________________________
PURCHASE
PRICE OF
% OWNED
MONTHLY
RENTAL
INCOME,
IF ANY
ESTIMATED
MARKET VALUE
OF % OWNED
$__________________
$________________
TOTAL PURCHASE
PRICE
(Enter this figure in
item 4, column A
on page 48.)
TOTAL CURRENT
MARKET VALUE
(Enter this figure in
item 4, column B
on page 48.)
Date______________________
Page 52
SCHEDULE “E” - CASH VALUE - LIFE INSURANCE
64. Indicate below the information requested with regard to the cash value of all life insurance policies held by you, your spouse or your dependent
children.
CHECK IF
HELD BY
SPOUSE
OR
DEPENDENT
CHILD
DATE
PURCHASED
INSURANCE CARRIER
POLICY NUMBER
BENEFICIARY(IES)
FACE
VALUE
CASH
SURRENDER
VALUE
ANNUAL
PREMIUM
PAYMENTS
EFFECTIVE
DATE
OF CASH
SURRENDER
VALUE
$____________________
TOTAL CASH
SURRENDER VALUE
(Enter this figure in
item 5, column B
on page 48.)
Initials___________
PHDMJ061901
Gaming Agency________________________________________
Date______________________
Page 53
SCHEDULE “F” - CASH VALUE - PENSION/RETIREMENT FUNDS
65. Indicate below the information requested with regard to the cash value of all retirement/investment/pension funds* held by you or your spouse.
CHECK
IF
HELD
BY
SPOUSE
TYPE
OF
FUND
TYPE OF
SECURITIES
HELD AND
ACCOUNT
NUMBER, IF ANY
EMPLOYER/
INSTITUTION
CUMULATIVE
EMPLOYEE
CONTRIBUTION
CUMULATIVE
EMPLOYER
CONTRIBUTION
CURRENT
CASH
VALUE
EFFECTIVE
DATE OF
CASH
VALUE
$________________
$_________________
TOTAL
CUMULATIVE
EMPLOYEE
CONTRIBUTION
(Enter this figure in
item 6, column A
on page 48.)
TOTAL
CURRENT CASH
VALUE
(Enter this figure in
item 6, column B
on page 48.)
*If you are filing this application in the United States, the information is to include IRA, 401K and KEOGH plans.
Initials___________
PHDMJ061901
Gaming Agency________________________________________
Date______________________
Page 54
SCHEDULE “G” - VEHICLES
66. Indicate below the information requested with regard to all vehicles owned or leased by you, your spouse, or your dependent children.
CHECK IF HELD
BY SPOUSE OR
DEPENDENT
CHILD
TYPE OF VEHICLE
SPECIFY IF
OWNED OR
LEASED*
DATE OF
PURCHASE/
LEASE
MODEL
YEAR
*If leased, specify in this column the length of the lease, total lease costs, down payments, monthly payments
and number of payments over the life of the lease.
**If leased, enter the sum of the down payment plus monthly payments to date as the total cost.
Initials___________
PHDMJ061901
Gaming Agency________________________________________
COST**
IF OWNED,
CURRENT MARKET
VALUE
$___________
$____________
TOTAL
COST OF
VEHICLES
(Enter this figure in
Item 8,column A on
page 48.)
TOTAL
CURRENT CASH
VALUE
(Enter this figure in
Item 8,Column B on
page 48.)
MAKE/ MODEL
OF VEHCILE
Date______________________
Page 55
SCHEDULE “H” - OTHER ASSETS
67. List below the information requested regarding all other assets, including any business investments in which any direct, indirect, vested or
contingent is held by you, your spouse or your dependent children. Business interests should include, but not be limited to, joint ventures,
partnerships, sole proprietorships, corporations and LLCs. Other assets should include, but not be limited to, art collections, coin collections, and
antiques.
CHECK IF
HELD BY
SPOUSE
OR
DEPENDENT
CHILD
Initials___________
PHDMJ061901
NATURE
OF
ASSET
COST
DATE OF
ACQUISITION
% OF
OWNERSHIP
INTEREST
DATE
OF
VALUATION
CURRENT
MARKET
VALUE
$___________________
$____________________
TOTAL
COST(S)
OF
OTHER ASSETS
(Enter this figure in
item 9, column A
on page 48.)
TOTAL CURRENT
MARKET VALUE
OF
OTHER ASSETS
(Enter this figure in
item 9, column B
on page 48.)
Gaming Agency________________________________________
Date______________________
Page 56
SCHEDULE “I” - NOTES PAYABLE
Initials___________
PHDMJ061901
INTEREST
RATE (%)
ACCOUNT
NUMBER,
IF ANY
DUE
DATE
NAME & ADDRESS
OF CREDITOR
DATE
INCURRED
CHECK IF
OWED BY
SPOUSE OR
DEPENDENT
CHILD
68. List below the information requested with regard to all notes payable for which you, your spouse or dependent children are obligated.
AMOUNT
OF
PERIODIC
PAYMENT/
PAY
PERIOD
Gaming Agency________________________________________
ORIGINAL
AMOUNT
OF NOTE
NATURE OF
SECURITY,
IF ANY
TOTAL
PAYMENTS
OUTSTANDING
AMOUNT OF
LIABILITY
$________________
$___________________
TOTAL ORIGINAL
AMOUNT OF
NOTES PAYABLE
(Enter this figure in
item 10, column C
on page 48.)
TOTAL AMOUNT
OF OUTSTANDING
NOTES PAYABLE
(Enter this figure in
item 10, column D
on page 48.)
Date______________________
Page 57
SCHEDULE “J” - LOANS AND OTHER PAYABLES
Initials___________
PHDMJ061901
NATURE
OF
ACCOUNT
Gaming Agency________________________________________
ORIGINAL
AMOUNT OF
LIABILITY
NATURE OF
SECURITY,
IF ANY
TOTAL
PAYMENTS
ACCOUNT
NUMBER,
IF ANY
INTEREST
RATE (%)
NAME & ADDRESS
OF CREDITOR
DUE
DATE
CHECK IF
OWED BY
SPOUSE OR
DEPENDENT
CHILD
DATE
OPENED
OR
INCURRED
69. List below the information requested with regard to all accounts payable (include lines of credit, installment loans, revolving charge accounts and
any other accounts) for which you, your spouse or your dependent children are obligated.
CURRENT
AMOUNT
OUTSTANDING
$__________
$___________
TOTAL
ORIGINAL
AMOUNT OF
LIABILITY
(Enter this figure in
item 11, column C
on page 48.)
TOTAL AMOUNT
OF OUTSTANDING
LOANS AND
OTHER
PAYABLES
(Enter this figure in
item 11, column D
on page 48.)
Date______________________
Page 58
SCHEDULE “K” - TAXES PAYABLE
70. List below the information requested with regard to all taxes payable for which you, your spouse, or your dependent children are obligated.
Only real estate and income taxes need to be included.
CHECK IF
OWED BY
SPOUSE
OR
DEPENDENT
CHILD
TAXING
AUTHORITY
DATE AND
AMOUNT OF
ORIGINAL
OBLIGATION
NATURE
OF TAX
FINES,
PENALTIES
AND INTEREST,
IF ANY
$_______________
TOTAL ORIGINAL
TAX
OBLIGATION(S)
(Enter this figure in
item 12, column C
on page 48.)
Initials___________
PHDMJ061901
Gaming Agency________________________________________
Date______________________
TOTAL
AMOUNT
DUE
$_______________
TOTAL AMOUNT
OF TAXES
PAYABLE
(Enter this figure in
item 12, column D
on page 48.)
Page 59
SCHEDULE “L” - MORTGAGES OR LIENS PAYABLE ON REAL ESTATE
ACCOUNT
NUMBER
ORIGINAL
AMOUNT OF
LIABILITY
DESCRIPTION/
ADDRESS OF
REAL ESTATE
$___________
PHDMJ061901
Gaming Agency________________________________________
CURRENT
MORTGAGE
BALANCE
$____________
TOTAL ORIGINAL
MORTGAGES OR
LIENS PAYABLE
ON REAL ESTATE
(Enter this figure in
item 13, column C
on page 48.)
Initials___________
AMOUNT OF
PERIODIC
PAYMENT/
PAY PERIOD
NAME AND ADDRESS
OF MORTGAGEE
OR LIEN HOLDER
TERM OF
MORTGAGE/
INTEREST
RATE (%)
CHECK IF
OWED BY
SPOUSE
OR
DEPENDENT
CHILD
DATE
INCURRED
71. List below the information requested with regard to all mortgages or liens due and owing on real estate for which you, your spouse or your
dependent children are obligated.
TOTAL
MORTGAGES OR
LIENS PAYABLE
ON REAL ESTATE
(Enter this figure in
item 13, column D
on page 48.)
Date______________________
Page 60
SCHEDULE “M” - LOANS AGAINST INSURANCE/PENSION PLANS
72. List below the information requested with regard to all loans against life insurance policies, pension plans, etc., taken by you, your spouse or
your dependent children.
CHECK IF
OWED BY
SPOUSE
OR
DEPENDENT
CHILD
INSURANCE CARRIER/
PENSION PLAN
ORIGINAL
AMOUNT OF
LOAN
PURPOSE
OF LOAN
INTEREST
RATE
(%)
DATE
OF
LOAN
$____________
TOTAL ORIGINAL
LIABILITY
INSURANCE/
PENSION LOANS
(Enter this figure in
item 14, column C
on page 48.)
Initials___________
PHDMJ061901
Gaming Agency________________________________________
Date______________________
PERIODIC
PAYMENT
AMOUNT/
PAY
PERIOD
CURRENT
LOAN
BALANCE
$______________
TOTAL AMOUNT
OUTSTANDING
INSURANCE/PENSION
LOANS
(Enter this figure in
item 14, column D
on page 48.)
Page 61
SCHEDULE “N” - ANY OTHER INDEBTEDNESS
73. List below the information requested with regard to any other indebtedness for which you, your spouse or your dependent children are obligated.
CHECK IF
OWED BY
SPOUSE
OR
DEPENDENT
CHILD
Initials___________
PHDMJ061901
NAME AND ADDRESS
OF CREDITOR
INTEREST
RATE
(%)
DESCRIPTION OF
LIABILITY, TYPE OF
OBLIGATION AND
NATURE OF
SECURITY,
IF ANY
Gaming Agency________________________________________
DUE
DATE
AMOUNT OF
PERIODIC
PAYMENT/
PAY PERIOD
Date______________________
ORIGINAL
AMOUNT OF
LIABILITY
OUTSTANDING
AMOUNT OF
INDEBTEDNESS
$_______________
$______________
TOTAL
ORIGINAL
AMOUNT OTHER
INDEBTEDNESS
(Enter this figure in
item 15, column C
on page 48.)
TOTAL AMOUNT
OUTSTANDING
OTHER
INDEBTEDNESS
(Enter this figure in
item 15, column D
on page 48.)
Page 62
SCHEDULE “O” - CONTINGENT LIABILITIES
74. List below the information requested with regard to all contingent liabilities for which you, your spouse or your dependent children are obligated.
CHECK IFOWED BY
SPOUSE
ORDEPENDENT
CHILD
Initials___________
PHDMJ061901
NAME AND ADDRESS
OF CONTINGENT
CREDITOR
DATE
INCURRED
ACCOUNT
NUMBER
PRIMARY
DEBTOR
Gaming Agency________________________________________
ORIGINAL
AMOUNT OF
CONTINGENT
OBLIGATION
CURRENT
AMOUNT OF
CONTINGENT
OBLIGATION
$__________________
$_________________
TOTAL
ORIGINAL
CONTINGENT
LIABILITIES
(Enter this figure in
item 16, column C
on page 48.)
TOTAL AMOUNT
OF OUTSTANDING
CONTINGENT
LIABILITIES
(Enter this figure in
item 16, column D
on page 48.)
DESCRIPTION
OF OBLIGATION
INCLUDING NATURE
OF SECURITY,
IF ANY
Date______________________
Page 63
75. Provide the names and other information requested of three (3) references over the age of 18
who have known you for at least one year and can attest to your good character and
reputation. No person can be a reference who is a member of your family. (Spouse,
parents, grandparents, children, grandchildren, siblings, uncles, aunts, nephews, nieces,
fathers-in-law, mothers-in-law, sons-in-law, daughters-in-law, brothers-in-law and sisters-inlaw whether by whole or half blood, by marriage, adoption or natural relationship.)
REFERENCE ONE
Name ____________________________________
Business Address__________________
Address __________________________________
_______________________________________
__________________________________________
_______________________________________
__________________________________________
_______________________________________
Telephone No. ______________________________
Occupation _____________________________
How long have you known the reference?
_______________________________________
REFERENCE TWO
Name ____________________________________
Business Address _________________
Address __________________________________
_______________________________________
__________________________________________
_______________________________________
__________________________________________
_______________________________________
Telephone No. ______________________________
Occupation _____________________________
How long have you known the reference?
_______________________________________
REFERENCE THREE
Name ____________________________________
Business Address _________________
Address __________________________________
_______________________________________
__________________________________________
_______________________________________
__________________________________________
_______________________________________
Telephone No. ______________________________
Occupation _____________________________
How long have you known the reference?
_______________________________________
Initials____________ Gaming Agency__________________________ Date___________________
PHDMJ061901
Page 64
76. As indicated in the instructions on page 2 of this form, this page is to be used by you for any
questions which require additional space to answer. The number of the question must be
stated immediately prior to your answer. If additional pages are needed, photocopy this page
or add paper of similar size and identify these pages with corresponding numbers and letters.
You must use blue ink to personally initial, date and identify the gaming agency to
which your application is being submitted at the bottom of any new page added.
IDENTIFY ALL ANSWERS BY ORIGINAL QUESTION NUMBERS
USE ADDITIONAL PAGES IF NECESSARY
Initials____________ Gaming Agency__________________________ Date___________________
PHDMJ061901
Page 65
STATEMENT OF TRUTH
STATE/PROVINCE OF ________________________________:
SS:
COUNTY/DISTRICT OF ______________________________:
___________________________________________, being duly sworn according to law deposes and says:
1. I am the applicant who is submitting this application form.
2. I personally supplied the information contained in this form.
3. I understand and read the English language or I have had an interpreter read, explain
and record the answer to each and every question on this application form.
4. Any document accompanying this Multi Jurisdictional Casino/Gaming License Personal History
Disclosure Form that is not an original document is a true copy of the original document.
5. I swear (or affirm) that the foregoing statements made by me are true. I am aware that if
any of the foregoing statements made by me are willfully false, I am subject to punishment.
DATED: ___________________________ ___________________________________ (LEGAL SIGNATURE)
(Signature of Applicant)
Subscribed and sworn to
before me this _____________________________ day
of __________________________________, _______
________________________________________________
NOTARY PUBLIC, JUSTICE OF THE PEACE/
COMMISSIONER FOR DECLARATIONS OR OTHER
PERSON AUTHORIZED TO TAKE DECLARATIONS
___________________________________
STATE/PROVINCE, COUNTRY
Initials____________ Gaming Agency__________________________ Date___________________
PHDMJ061901
Page 66