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CCC:PHDF2 PERSONAL HISTORY DISCLOSURE FORM 2 Vp tL LL NMENT G toxee iy pro f Ae er i age fine PF ¥: Fe 6 os ahhns sas AN = { SY. Te C7 Ss Et TES VIR Sear ge, UNITED STATES VIRGIN ISLANDS Rev. 7/00 Virgin Islands Casino Control Commission 3005 Orange Grove Christiansted, St. Croix United States Virgin Islands 00820 Telephone: 340-718-3616 • Fax: 340-718-3136 Initial Application: Additional Documentation required to be submitted with your Application: 1. Finger print card 2. Background check 3. 2 passport size pictures 4. 2 Government issued I.D. (i.e. V.I. Driver's license, Passport and/or Voter's I.D.) 5. Birth Certificate 6. Social Security Card 7. Naturalization Document or U.S. Passport 8. Offer letter 9. Tax documents (last 3 years) 10. High School Diploma Renewal Application: 1. Finger print card 2. Background check 3. 2 passport size pictures 4. 2 Government issued I.D. (i.e. V.I. Driver's license, Passport and/or Voter's I.D.) 5. Tax documents (last 3 years) 10. 11. 12. 13. 14. PERSONAL HISTORY DISCLOSURE FORM 2 APPLICATION INSTRUCTIONS You are to complete this application if you are: a. An applicant for an initial 3-year casino employee license; or b. An applicant for an initial 3-year gaming school employee license; or c. Directed to do so by the Casino Control Commission (Commission). Read this entire form carefully before answering any of the questions. Answer every question completely and truthfully. DO NOT LEAVE ANY BLANK SPACES. Ifa question does not apply to you, indicate “Does not apply” in response to that question. If there is nothing to disclose t a particular question, state “None” in response to that question. All entries on this form, except signature, must be typed or block printed in black ink. If your application is not legible, it will not be accepted. Initial each page of this form in the space provided after you have checked your answers and are sure they are complete and correct. Sign the Statement of Truth, the Release Authorization and Release of all Claims in the presence of a Notary Public. Attach to this form a copy of your birth certificate. If your birth certificate is not available, one of the following will be accepted: a. your notarized statement confirming your date and place of birth. b. Naturalization papers. Attach to this form a copy of your Social Security Card and a copy of a government-issued I.D. All persons completing this application form must be fingerprinted. Appropriate fingerprint cards must accompany this application. Submit an original and one (1) copy of this entire form to the U.S. Virgin Islands Casino Control Commission. Once filed, you may not withdraw your application without the permission of the U.S. Virgin Islands Casino Contre! Commission. We recommend that you keep a copy of your completed application for your records. IMPORTANT! Staple two recent photographs within the box. Print name on rear of photographs. EXHIBITS: All attachments requested in this form shall be referred to by exhibit number and attached to the back of this form. Rev. 7/00 1 Initials U.S. VIRGIN ISLANDS CASINO CONTROL COMMISSION VICCC Use Only (print or type all answers) OCCUPATION APPLIED FOR: SIGNATURE OF EMPLOYER SIGNATURE OF APPLICANT EMPLOYER SIGNATURE ABOVE CERTIFIES THAT THE APPLICANT NAMED HEREIN HAS BEEN OFFERED A POSITION AND HAS OR WILL BE TRAINED IN THE OCCUPATION INDICATED AND WILL BE EMPLOYED IF LICENSED. NAME: (Last) (First) (Middle) Mailing Address: (City) (State) (Zip Code) Daytime Phone No. Physical Address (ome): (City) (State) (Zip Code) Evening Phone No. DATE OF BIRTH: Maiden Name: Height Weight Social Security #: ALIASES OR NICKNAMES: DRIVER’S LICENSE INFORMATION STATE: NUMBER: PLEASE CHECK (for statistical purposes only) SEX RACE Male Caucasian Female Black Hispanic American Indian Other Attach a passport size photograph in each box. Print your name on the back of each photograph before attaching. Rev. 7/00 2 Initials bs Have you been known by any name or names other than as listed on previous page? Ifyes, list the additional names below and specify dates of use for each. 2: Of what country are you a citizen? A. Please indicate: 1. Place of birth (City, State, Country): De Country of birth: B. If you are not a citizen of the United States, please indicate: Js Port of entry to the United States: 2. Name and address of sponsor upon your arrival: 3. If you are a naturalized citizen, provide the following information: PETITION NUMBER DATEGRANTED COURT CITY/STATEOF COURT CERTIFICATE NUMBER 4. If you are a legally authorized Permanent Resident Alien, provide the “A” number from your Alien Registration Card (I 151 or 1551). De If you do not have an Alien Registration Card but are an alien authorized to be employed in the United States, please provide the “A” number from that authorization. 6. Have you lived in the U.S. Virgin Islands continuously for (5) years or more? Yes No If answer is no, state how long you have lived continuously in the U.S. Virgin Islands: Rev. 7/00 3 Initials RESIDENCE DATA 6. Beginning with your current residence(s) and working backwards, provide the following information with respect to each place where you have lived during the past five years. DATES FROM: TO: (MO/YR) | (MO/YR) ADDRESS (No., Street, Apt., City, State, Country & Zip Code) TELEPHONE NUMBER Rev. 7/00 Initials FAMILY DATA f Circle your current marital Status: Single Married Legally Separated Divorced A. Give the name of your present spouse: 8: List all former spouses: MILITARY SERVICE DATA 8. Have you ever served in a military organization of the United States or been an active member of the Reserve Forces of the United States? Yes No If yes, provide the following information: Branch of Service: Service Serial #: Highest Rank Held: Period(s) of Active Service: FROM: TO: FROM: TO: a Indicate your type of discharge or separation from Military Service(s): (Honorable, Dishonorable, Honorable Conditions, Medical, etc.) 10. Have you ever been tried by military court martial or have you had charges filed against you under Article 15 of the Uniform Code of Military Justice (Summary court, deck court, captain’s mast, company punishment, etc.) Yes No Ifyes, give details of the charge(s) and their disposition(s). NOTE: Attach to this form a copy of your military record (DD214). If unavailable, provide a copy of a letter to the appropriate branch of military indicating that you requested your Military Service information. If discharged prior to 1951, please indicate such. If in reserves, please attach a copy of your discharge papers. Rev. 7/00 5 Initials EDUCATIONAL DATA Il. Beginning with secondary (high school) education, provide the information listed below with respect to each school, college, graduate or post graduate school, vocational or other employment training program which you have attended. Be sure to include participation in certified Territorial casino gaming training courses. If applicable and available, attach a copy of your graduation certificate from the gaming school attended. DATES NAME AND ADDRESS OF | DESCRIPTION OF | LIST ANY DEGREE SCHOOL, TRAINING EDUCATIONAL | OR CERTIFICATION PROGRAM, ETC. PROGRAM ATTAINED FROM: TO: (MO/YR) (MO/YR) | Rev. 7/00 Initials 12. EMPLOYMENT AND LICENSING DATA Provide the information listed below as to each place in which you have been employed for the past ten (10) years. 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. Note by means of an asterisk (*) any gaming-related employment (such as casino gaming, horse racing or dog racing, parimutuel operation, lottery, sports betting, etc.) DATES NAME, MAILING ADDRESS TITLE, POSITION HELD REASON FOR FROM: (MO/YR MO/YR SUPERVISOR. AND PHONE NUMBER OF AND DESCRIPTION OF LEAVING EMPLOYER(S). INCLUDE DUTIES TO: NAME OF IMMEDIATE Rev. 7/00 7 Initials 12: Have you ever before applied to the Virgin Islands Casino Control Commission for any license, permit approval or registration? Yes ___No. If yes, complete the following chart: TYPE OF LICENSE, DATE DISPOSITION (GRANTED, IF ISSUED, GIVE PERMIT, APPROVAL OR | APPLICATION PENDING, DENIED) APPROPRIATE REGISTRATION WAS FILED NUMBER(S) PREVIOUSLY APPLIED FOR 14. Have you ever applied in any other jurisdiction for a license, permit or other authorization to participate in a lawful gambling operation (including casino gaming, horse racing, dog racing parimutuel operation, lottery, sports betting, ete.?) Yes No. If yes, complete the following chart: TYPE OF POSITION DATE OF NAME AND ADDRESS | DISPOSITION IF ISSUED, GIVE ] GAMBLING | SOUGHT OR | APPLICATION OF LICENSING (GRANTED, APPROPRIATE APPROVAL HELD AGENCY DENIED OR NUMBERS (INCLUDE COUNTRY, PENDING) STATE, COUNT OR MUNICIPALITY) 15. Have you ever had any license, permit or certificate denied, suspended or revoked by any governmental agency? (Do not include driver’s license.) Yes No If yes, complete the following chart: TYPE OF LICENSE, NAME & ADDRESS OF DATE OF DENIAL, REASON(S) FOR PERMIT OR GOVERNMENTAL SUSPENSION OR DENIAL, CERTIFICATE AGENCY REVOCATION SUSPENSION OR REVOCATION Rey. 7/00 a Initials CIVIL, CRIMINAL AND INVESTIGATORY PROCEEDINGS Question #16 asks about any arrests, charges or offenses you may have committed. Prior to answering this question, carefully review the definitions and instructions which follow. For purposes of this question: DEFINITIONS 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.” D. “Offense” includes all felonies, crimes, misdemeanors, disorderly conduct offenses and any other types 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; The charges were dismissed C. You completed a Pretrial Intervention Program (PIP) or equivalent diversionary program in any jurisdiction; 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” JF: A. The records relating to the arrest or charges have been expunged or sealed by court order; AND B. You attach a copy of the expungment or sealing order to this application. Rev. 7/00 9 Initials 16. this Territory or anywhere else? Yes Have you ever been arrested or charged with any crime or offense (other than a traffic violation) in No If yes, complete the following chart: NATURE OF CHARGE OR ARREST DATE OF CHARGE OR ARREST NAME AND ADDRESS OR LAW ENFORCEMENT AGENCY OR COURT INVOLVED DISPOSITION (CONVICTED, ACQUITTED, DISMISSED, PENDING, PARDONED, ETC.) SENTENCED 17. Have you ever been called to testify before, been the subject of an investigation conducted by, or requested to take a polygraph exam by any governmental agency, court, committee, grand jury or investigatory body (municipal, state, territory, county, provincial, federal, national, etc.) other than in response to a traffic summons? Yes No Ifyes, complete the following chart: NAME AND ADDRESS OF COURT OR OTHER AGENCY NATURE OF PROCEEDINGS OR INVESTIGATION WAS TESTIMONY GIVEN DATE ON WHICH TESTIMONY WAS GIVEN APPROXIMATE TIME PERIOD INVESTIGATION OF Rev. 7/00 10 Initials 18. a) Have you ever been a party to a lawsuit? (Include matrimonial matters, negligence matters, auto accident matters, contract matters, collection matters, debt matters, etc.) Yes No b) Have you ever had any financial liens filed against you? (include federal tax liens, employment judgments, defaulted student loans, etc.) Yes No If yes to either question, complete the following chart: DATE JURISDICTION | DOCKET OTHER NATURE | DISPOSITION DATE OF FILED NUMBER | PARTIES TO | OF SUIT DISPOSITION SUIT FINANCIAL DATA 19; Within the past 10 years, have you held an ownership interest in any business(es)? (Do not include publicly traded corporations in which you owned stock.) Yes No If yes, beginning with the most recent and working backwards, provide the following information with regard to all business(es) in which you have held an ownership interest. DATES NAME(S) AND CURRENT % OF INTEREST NAME(S) OF ADDRESS(ES) OF STATUS OF HELD BY YOU OTHER FROM: TO: BUSINESS(ES) BUSINESS(ES) OWNER(S) (MO/Y¥YR (MO/YR _ | Rev. 7/00 11 Initials 20. Have you personally ever been adjudicated bankrupt or filed a petition for any type of bankruptcy or insolvency under any bankruptcy insolvency law? bankruptcy petition and discharge if granted. If yes, also complete the following chart: Yes No If yes, attach a copy of the DATE FILED DOCKET NUMBER NAME & ADDRESS OF | NAME AND ADDRESS COURT OF TRUSTEE 21. Has any business entity in which you held 10% or greater ownership (other than ownership of stock in a Publicly Traded corporation) or in which you served as an officer or director ever been adjudicated bankrupt or filed a petition for any type of bankruptcy or insolvency under any bankruptcy or insolvency law? Yes No Ifyes, complete the following chart: DATE DOCKET NAME & ADDRESS OF | NAME & ADDRESS OF | NAME & ADDRESS FILED NUMBER COURT FILING PARTY OF TRUSTEE Rev. 7/00 Initials 22. 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? __Yes No If yes, complete the following chart: DATE DOCKET | NAME & ADDRESS OF | NATURE OF AMOUNT OF NAME & FULED NUMBER COURT OBLIGATION | OBLIGATION | ADDRESS OF HOLDER OF OBLIGATION 23. Do you have any bank accounts or safe deposit boxes in your name? Yes __—'No Do you have access to the funds in any other bank accounts or safe deposit boxes? _ Yes No If yes to either question, complete the following chart: NAME & ADDRESS OF NAME(S) IN WHCH TYPE OF ACCOUNT, ACCOUNT NO. | BANK ACCOUNT(S) OR SAFE (SAVINGS, CHECKING, OR SAFE DEPOSIT BOX(ES) HELD SAFE DEPOSIT, ETC.) DEPOSIT BOX NO. Rev. 7/00 13 Initials 24. Provide the names and other information requested of three (3) references over the ageof 18 who have — known you for at least one year and can attest to your good character, reputation and business ability. 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-in-law whether by whole or half-blood, by marriage, adoption or natural relationship.) REFERENCE ONE Name: MAILING Address: Physical Address: Occupation: How long have you known the reference? _ Telephone No.: REFERENCE TWO Name: - MAILING Address: Physical Address: Occupation: How long have you known the reference? _ Telephone No.: REFERENCE THREE Name: MAILING Address: Physical Address: Occupation: How long have you known the reference? Telephone No.: Rev. 7/00 14 Initials 25. 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 the answer. If additional pages are needed, photocopy this page or add paper of similar size and identify these pages with corresponding numbers and letters. Be sure to include your initials at the bottom on any new page added. IDENTIFY ALL ANSWERS BY ORIGINAL QUESTION NUMBERS Rev. 7/00 15 Initials STATEMENT OF TRUTH STATE OF ) SS. COUNTY OF ) , being duly sworn according to law deposes and says: (Print Name ) (Place your initials in appropriate response.) 1. I am the applicant who is submitting this application form. 2. I personally supplied the information contained in this form. 1 swear/affirm that the information contained in this form is true to the best of my knowledge and belief. | swear/affirm that the foregoing statements made by me are true. | am aware that if any of the foregoing statements made by me are willfully false, | am subject to termination and/or punishment. (SIGNATURE OF APPLICANT) Interpreter's Name Interpreter's Signature Language spoken, if not English SUBSCRIBED and sworn to before me this day of , 20 NOTARY PUBLIC Commission Expiration Date RELEASE OF ALL CLAIMS The undersigned has filed with the U.S. Virgin Islands Casino Control Commission an application for a license. In consideration of the assurance by the Commission that no vote on said application will be taken except after deliberate, intensive and thorough investigation of the undersigned, including but not limited to background, family, associates and finances, the undersigned does for myself, my heirs, executors, administrators, successors and assigns, hereby release, remise and forever discharge the Government of the US. Virgin Islands, its instrumentalities and agents, including the U.S. Virgin Islands Casino Control Commission, its members, agents, and employees, from any and all manner of actions, causes of actions, suites, debts, judgments, executions, claims and demands whatsoever, known or unknown, in law or equity which the undersigned ever had, now has, may have, or claim to have, against any or all of said entities or individuals arising out of or by reason of the processing of the license or the investigations or hearings or other action relating to the undersigned’s application for a license. E the undersigned, having read this release, execute it (Print Name) voluntarily with full knowledge of its significance. Date: SIGNATURE OF APPLICANT Date of Birth: Social Security #: SUBSCRIBED and SWORN to before me this day of NOTARY PUBLIC Commission Expiration Date RELEASE AUTHORIZATION To All Courts, Probation Departments, Selective Service Boards, Employers, Educational Institutions, Banks Financial and Other Such Institutions, And All Governmental Agencies - federal, state and local, without exception both foreign and domestic. 2 2 I have authorized the U. S. Virgin Islands Casino Control Commission (Print Applicant Name) and/or The Department of Justice Division of Gaming to conduct a full investigation into my background and activities. Therefore, you are hereby authorized to release any and all information pertaining to me, documentary or otherwise, as requested by any employee or agent of the U. S. Virgin Islands Casino Control Commission and/or The Department of Justice Division of Gaming, provided that he or she certifies to you that I have an application pending before the U. S. Virgin Islands Casino Control Commission, or that I am presently a licensee, registrant or person required to be qualified under the provisions of the applicable U. S. Virgin Islands Casino Control Commission's Regulations. This Authorization shall supersede and countermand any prior request or authorization to the contrary. A photostatic copy of this Authorization will be considered as effective and valid as the original. Date: (Signature of Applicant) Date of Birth: Social Security #: SUBSCRIBED and sworn to before me this day of , 20 NOTARY PUBLIC Commission Expiration Date Seal