Non-Gaming Employee License Form

MARYLAND STATE LOTTERY COMMISSION
1800 Washington Blvd., Suite 330, Baltimore, Maryland 21230
Applicant:________________
Non-Gaming Employee
License Form
VLT Form – 2002 (Rev 091010)
Page 1 of 12
Initials______________
Non-Gaming Employee License Application
Maryland State Lottery Commission
APPLICATION AND REGISTRATION FEES
1.
2.
3.
4.
5.
6.
Application fee………………………………………………………… $ 50.00
Finger print processing fee……………………………………………. $ 37.25
License fee…………………………………………………………….. $ 100.00
Initial term………………………….…………………………………. 3 Year
Renewal fee…………………………………………………………… $ 100.00
Renewal term………………………………………………………….. 3 Year
Note: License, Application & fingerprint fees are due at the time of application. They are
non-refundable. You may wire transfer your payment or send it to the following address:
Payment is sent to:
Maryland State Lottery Agency
Attn: Support Services
1800 Washington Blvd, Suite 330
Baltimore, Maryland 21230
The application is sent to the same address, except: Attn: VLT Licensing Division.
PAYMENT FORM: MUST be sent as a certified/bank check or money order.
“DO NOT SEND THE APPLICATION AND
PAYMENT TOGETHER”
VLT Form – 2002 (Rev 091010)
Page 2 of 12
Initials______________
Non-Gaming Employee License Application
Maryland State Lottery Commission
MARYLAND STATE LOTTERY COMMISSION
VIDEO LOTTERY Non-GAMING EMPLOYEE LICENSE APPLICATION
I.
PERSONS REQUIRED TO OBTAIN A VIDEO LOTTERY Non-GAMING EMPLOYEE LICENSE:
a. This application must be completed by an individual who is employed or is seeking to be employed by an
applicant for or holder of an operation license, whose duties are or will be other than the duties of a gaming
employee. A non-gaming employee’s duties do not involve the maintenance or operation of gaming activity
or equipment and associated assets, and do not regularly require the individual to work in restricted areas,
on the gaming floor, or in any other gaming-related functions or activities.
II. 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 or you have nothing to disclose, indicate “Does Not Apply” in
response to that question. Failure to provide a response to every question could result in the denial of your
application.
c.
If the space available is insufficient to respond to a question, supply the required information on an
attachment page and clearly identify which question you are answering.
d. If you make any modification to the pre-printed questions or information contained in this form, your
application may be denied. Once your application is submitted, it becomes the property of the Maryland
State Lottery Agency and will not be returned.
III. BE SURE:
a. You sign the Statement and Authorization at the end of this form in the presence of a notary public or
other person authorized to authenticate your signature.
b. You retain a completed copy of your application for your own records.
IV. PHOTOGRAPH AND FINGERPRINTS
a. You will be required to have your photograph taken when your application is made.
b. You will be required to submit fingerprints upon application.
NOTE: AN APPLICATION THAT HAS BEEN ACCEPTED FOR FILING AND ALL RELATED MATERIALS
SUBMITTED TO THE COMMISSION SHALL BECOME THE PROPERTY OF THE COMMISSION AND WILL
NOT BE RETURNED TO THE APPLICANT.
VLT Form – 2002 (Rev 091010)
Page 3 of 12
Initials______________
Non-Gaming Employee License Application
Maryland State Lottery Commission
Name of Gaming Licensee:
(You must have an offer to work from a Licensee)
Type of Licensee
Operator
Manufacturer
Contractor
Position Applicant is Applying for:
NAME AND ADDRESS
1. Last Name
First Name
Middle Name
Suffix(Jr., Sr., etc.)
2. Maiden Name
3. Date of Birth
4. Address Line 1
Address Line 2
Address Line 3
City
Zip Code
County
Country
5. Email Address
State/Province
6. Home Phone
7. Cell Phone
Mailing Address (If different from above)
8. Address Line 1
Address Line 2
Address Line 3
City
Zip Code
County
Country
Email Address
State/Province
Home Phone
Cell Phone
DESCRIPTIVE INFORMATION
9. Height
10. Weight
11. Social Security Number
12. Drivers License __________________________
________FT
_________IN
_______________lbs
__________-_______-___________
13. Do you have any Tattoos, scars or distinguishing marks? If yes,
describe in detail:
14. MARITAL STATUS:
15. PLACE OF BIRTH:
City/Town
State/Province
Country
SINGLE
MARRIED
SEPARATED
DIVORCED
WIDOWED
DOMESTIC PARTNERSHIP
16. Name of Spouse/Partner
17. Spouses Maiden Name
(AKA)
18. DOB
20. HAIR COLOR
21. EYE COLOR
22. SEX
(BK)Black
(BR) Brown
(BK) Black
(BR) Brown
(BD) Blonde
(RD) Red
(HZ) Hazel
(BL) Blue
(GY) Gray
(WH) White
(GY) Gray
(GR) Green
State Issued: ________________________________
19. Spouse’s/Partner Social Security Number
23. RACE*
Are you of Hispanic/Latino origin?
(M) Male
Caucasian
(F) Female
Native Hawaiian/Pacific Islander
Yes
No
Black/African American
American Indian/Alaska Native
Asian
Other:_________
* Multiracial respondents may select all applicable racial
categories.
(BA) Bald
LIST ANY OTHER NAME OR NAMES YOU HAVE BEEN KNOWN BY (INCLUDE ALIASES; NICKNAMES; MARRIED NAMES)
24. Have you been known by any other name or names?
YES
NO If YES, list the additional names below and
specify dates for use for each. Include maiden name, aliases, nicknames or any other names used.
FIRST NAME
MIDDLE NAME
SUFFIX
FROM
TO
LAST NAME
DATE
DATE
VLT Form – 2002 (Rev 091010)
Page 4 of 12
Initials______________
Non-Gaming Employee License Application
25. Are you a United States citizen?
YES
Maryland State Lottery Commission
NO
If NO, complete the following:
a. Country of Citizenship:
Name and Address of sponsor
upon your arrival:
b. If a naturalized citizen complete:
c.
d.
1.
2.
3.
4.
5.
C.T.S. Registration Number:_____________________________
Date Granted: _______________________________________
Court:_______________________________________________
City/State of Court:_____________________________________
Certificate Number:_____________________________________
If you are a legally authorized Permanent Resident Alien, provide the “A” number from your Permanent Resident Card:
Card Number:_________________________________ (Attach a color copy front and back)
If you do not posses a Permanent Resident Card but are authorized to work in the United States, please describe the U. S. Work Visa that
you possess and provide the Visa number:
Description of Authorization:____________________________
VISA #:_____________________________________________
26. Have you ever been issued a passport?
Passport Number
Country of Issue
YES
NO
Place Issued
If, yes please complete the following:
Date Issued
Expiration Date
RESIDENCE
27. Beginning with your current residence(s) and working backwards complete the following information for each
place where you have lived (including residences while attending college or while in the military service) during the
past three (3) years or since the age of 18, whichever is less. If additional space is needed, attach a separate sheet making
certain to indicate the question number.
Dates
From:
(Mo/Yr)
To:
(Mo/Yr)
Address
(no, street, apt. #, City/town, state/province, zip
code
VLT Form – 2002 (Rev 091010)
Page 5 of 12
Own
Or
Rent
Name, address & telephone no. of Landlord
or Mortgage Company, if any.
Initials______________
Non-Gaming Employee License Application
Maryland State Lottery Commission
EMPLOYMENT
28. Beginning with your present job and working backwards, list below all periods of employment for the past three
years or from age 18, which ever is less. 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, horse racing or gaming
related employment, please list your license number under “Title.” (If additional space is needed, attach a separate
sheet making certain to indicate the question number.)
Dates
From:
To:
(Mo/Yr)
(Mo/Yr
Name, Address and telephone Number
of Employer(s)
Title/Position Held and
Description of Duties
29. Have you ever been discharged or asked to resign from a job?
Employers Name & Address
VLT Form – 2002 (Rev 091010)
Date of Discharge or
Resignation
Page 6 of 12
No
Supervisors
Name
Reason for leaving/
Compensation at
Departure
Yes If Yes, complete below.
Reason for Leaving
Initials______________
Non-Gaming Employee License Application
Maryland State Lottery Commission
CIVIL, CRIMINAL & INVESTIGATORY PROCEEDINGS
Prior to answering this question, carefully review the definitions and instructions which follow.
DEFINITIONS:
For purposes of this question:
A. “Arrest” includes any time that you were stopped by any law enforcement officer and advised that you were under
arrest, detained, held for questioning or were requested by a law enforcement officer to come to a law enforcement
office or facility and answer questions. “Arrest” also includes any circumstances in which you were taken into
custody by any law enforcement officer, fingerprinted, detained in any jail or detention center, or otherwise been the
subject of a court order to appear in a judicial proceeding in which you were accused of a “crime or offense” as
defined in subsection C.
B. “Charge” includes any indictment, complaint, information, summons, or other notice of the alleged commission of
any “offense.”
C. “Offense” includes all felonies, misdemeanors, and summary offenses that may have required you to appear before
any municipal, state, or federal grand jury, court, or any other judicial tribunal except juvenile court. “Offense” also
includes all driving-related charges or offense which carry any period of incarceration.
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 downgraded to a lesser charge;
C. You completed a pretrial intervention or other rehabilitation or diversionary program;
D. You were not convicted;
E. You did not serve any time in a correctional facility;
F. The charges or offenses happened a long time ago; or
G. You were not arrested for the charge.
2. Answer “NO” IF any records relate to a charge, arrest or conviction in juvenile court, or have otherwise been expunged
or officially sealed by a Court or government agency.
I have read and understand the definitions and instructions
IMPORTANT
Maryland will make inquiries to establish whether the identified individuals have had any involvement with law
enforcement agencies.
Failure to disclose any such involvement will be taken into account in
assessing the Applicant’s character, honesty and integrity. Do you understand?:
YES
NO
30. Have you ever been arrested or charged with any offense in any jurisdiction?
If yes, complete the following chart:
Disposition
Name and Address of
Nature of Charge or
(Convicted,
Date of Charge or
Law Enforcement
Offense/Location of Where
Acquitted,
Offense
Agency or Court
Incident Occurred
Dismissed, Pending,
Involved
Pardoned, etc.)
VLT Form – 2002 (Rev 091010)
Page 7 of 12
YES
NO
Sentence
(if any)
Initials______________
Non-Gaming Employee License Application
Maryland State Lottery Commission
31. To the best of your knowledge, has a criminal indictment, information or complaint ever been filed or returned
against you, or named you 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
Outcome/Disposition
Date
32. To the best of your knowledge, 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 connection with a traffic summons?
YES
NO
If yes, complete the following chart:
Name and Address of Court or
Other Agency
Nature of Proceeding
or Investigation
Was
Testimony
Given?
Date on which
Testimony
was Given
Approximate Time Period of
Investigation
PERMITS, LICENCES, CERTIFICATES & REGISTRATIONS
33. Have you, or any business entity with which you are or were associated, ever applied for any permit, license,
certificate or registration in connection with gaming in any jurisdiction?
No
Yes If yes, complete below.
Name & Address of
Applicant
VLT Form – 2002 (Rev 091010)
Name & Address of
Licensing Body
Type of Permit, License,
Certificate or
Registration
Page 8 of 12
Date of Application
Disposition: Granted,
Denied, Pending,
Withdrawn
Initials______________
Non-Gaming Employee License Application
Maryland State Lottery Commission
Illegal Use of Controlled Dangerous Substances;
Use of Alcohol in the Workplace; Problem Gambling
(Answer all questions and provide information to any question you answer “yes.”)
34 Do you currently engage in the illegal use of drugs, or have ever been arrested for such use?
yes, please explain below.
No
Yes if
35 The use of alcohol by licensees may be prohibited in a VLT facility, and any use of alcohol that adversely affects job
performance or conduct maybe the basis for discipline of video lottery employees and revocation or suspension of a
VLT license. Does this present a problem for you?
No
Yes if yes explain below.
36 Are you a compulsive gambler, or have you ever been voluntarily or involuntarily excluded from any gaming facility?
No
Yes if yes, please explain listing the jurisdiction, if applicable.
Item #
VLT Form – 2002 (Rev 091010)
Detail Explanation (Dates, jurisdictions, etc, as applicable for full explanation)
Page 9 of 12
Initials______________
Non-Gaming Employee License Application
Maryland State Lottery Commission
AUTHORIZATION FOR RELEASE OF INFORMATION
TO: ___________________________________________________________________
(To be filled-in by Commission)
FROM: ________________________________________________________________
(Applicant’s Printed Name)
I am an applicant for a video lottery terminal license in the State of Maryland.
The Maryland State Lottery Commission is required by law to conduct an investigation of an applicant for a video lottery
terminal license. That investigation requires the Commission to collect and evaluate information about me. I irrevocably give
consent to the Maryland State Lottery Commission, the Video Lottery Facility Location Commission, the Maryland State
Police, and persons authorized by the Commission, to: (1) verify all information provided in the license application documents;
(2) conduct a background investigation of me; and to have access to any and all information that I have provided to any other
jurisdiction seeking a similar license in that jurisdiction, as well as the information obtained by that other jurisdiction during the
course of any investigation that it may have conducted about me.
By executing this Authorization, I authorize any: local, State or federal government unit; commercial or business enterprise;
non-profit entity; individual; or any other public or private entity, to release to the Commission any and all information about
me that the Commission requests. The requested information may be released in written, verbal, electronic, or any other form.
With respect to any claims or liability arising from the release of the requested information to the Commission, I expressly
waive, release, discharge and forever hold harmless and agree to indemnify, the unit, entity, or individual that releases
information to the Commission under the authority of this Authorization.
A photo, facsimile, or electronic copy of this signed and dated Authorization shall be equally effective as an original.
____________________________________
________________________________
Signature of Applicant
Date
___________________________________________
Print Name of Applicant
NOTARY
The undersigned, a Notary Public in and for the County of ______________________, in the State of
_______________________, certifies that the above named individuals appeared in person, and before me, either known to me
or satisfactorily proven to be the individuals whose name subscribed to the within instrument and signed the Authorization and
Notification.
This _________ day of _________________________, 20_____, and to which witness my hand and seal.
____________________________________
Notary Public
Stamp or Seal
____________________________________
Printed Name
My commission expires _________________, 20____
VLT Form – 2002 (Rev 091010)
Page 10 of 12
Initials______________
Non-Gaming Employee License Application
Maryland State Lottery Commission
AFFIDAVIT OF INDIVIDUAL APPLICANT
I, _____________________________________ (printed name) am an applicant for a video lottery license
in the State of Maryland. I have read, and understand, every page of this Form. To the best of my
knowledge, information, and belief, the information that I have provided on, or attached to, this Form is
accurate, complete, and not misleading. I understand that any misrepresentation or omission may lead to
the delay or denial of my application for a video lottery terminal (“VLT”) license, and may subject me to
civil or criminal liability.
By a separate Authorization for Release of Information, I am authorizing any entity or individual that has
information about me to release that information to the Maryland State Lottery Commission, its
employees, agents, and vendors (collectively, “the Commission”), for purposes of its investigation of the
application for a VLT license.
I expressly waive, release, discharge, and forever hold harmless and agree to indemnify, the Commission,
the State of Maryland, and their employees, agents, and representatives, from liability for any and all
claims or legal action arising from any actions that the Commission or the State of Maryland may take
related to the collection of information from the any individual or person and the use of that information in
connection with investigating the application for a VLT license.
.
_______________________________________
_____________________________
SIGNATURE OF APPLICANT
DATE
__________________________________________________
PRINT NAME OF APPLICANT
NOTARY
The undersigned, a Notary Public in and for the County of ______________________, in the State of
_______________________, certifies that the above named individuals appeared in person, and before
me, either known to me or satisfactorily proven to be the individuals whose name subscribed to the within
instrument and signed the Authorization and Notification.
This _________ day of _________________________, 20_____, and to which witness my hand and seal.
____________________________________
Notary Public
Stamp or Seal
____________________________________
Printed Name
My commission expires _________________, 20_____
*NOTE: If Application is filed electronically, through the licensee facility directly to the
LOTTERY, notarization is NOT required.
VLT Form – 2002 (Rev 091010)
Page 11 of 12
Initials______________
Non-Gaming Employee License Application
Maryland State Lottery Commission
CERTIFICATION OF BUSINESS RELATIONSHIP
LICENSEE: _____________________________________________________________
APPLICANT: ___________________________________________________________
(Applicant’s Printed Name)
I, _____________________________________ (printed name), am authorized to complete and execute
Business Agreements on behalf of _____________________________ (Licensee Name). The applicant
listed above has entered into an agreement/contract to work for this licensee.
The Applicant will have the following job description:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
__________________________________________
______________________________
Signature of Licensee Representative
Date
(If electronic no signature required)
__________________________________________________
Printed Name
____________________________________
Title
NOTARY
The undersigned, a Notary Public in and for the County of ______________________, in the State of
_______________________, certifies that the above named individual appeared in person, and before me, either known to me
or satisfactorily proven to be the individual whose name subscribed to the within instrument and signed the Authorization and
Notification.
This _________ day of _________________________, 20_____, and to which witness my hand and seal.
Stamp or Seal
My Commission expires________________, 20_____
____________________________________
Notary Public
____________________________________
Printed Name
*NOTE: If Application is filed electronically, through the licensee facility directly to LOTTERY, this
form is NOT required.
VLT Form – 2002 (Rev 091010)
Page 12 of 12
Initials______________