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CCC:CHERA.1 REGISTRATION APPLICATION For: CASINO HOTEL EMPLOYEE CASINO HOTEL SECURITY EMPLOYEE CASINO SERVICE EMPLOYEE Lf FI ALLL LSS MENTO 4 Ko +0 ee Oo er > hh. Xe & \ ss DA > f Co ——* 4O Sw, Sy MIS DY TES VIR YS IL TT a LI LD 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. 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.) U.S. VIRGIN ISLANDS CASINO CONTROL COMMISSION OCCUPATION APPLIED FOR: SIGNATURE OF EMPLOYER VICCC use only 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 OR REGISTERED. NAME: (Last) (First) (Middle) ADDRESS: (Number and Street) (City) (State) (Zip Code) Phone No. (Day) Mailing Home: Phone No. (Evening) DATE OF BIRTH: Maiden Name: Height Weight Social Security #: ALIAS OR NICKNAME : DRIVERS LICENSE INFORMATION STATE NUMBER Attach a passport size photograph in each box. Print your name on the back of each photograph before attaching. Rev. 7/00 INITIALS J. Of what country are you a citizen? A. Please indicate: _1. Place of birth (City, State, County): 2. Country of birth: B. If you are not a citizen of the United States, please indicate: 1. Port of entry to the United States: 2. | Name and address of sponsor upon your arrival: 2. If you are a naturalized citizen, provide the following information: PETITION NUMBER DATE GRANTED COURT CITY/STATE OF CERTIFICATE COURT NUMBER 3. If you are a legally authorized Permanent Resident Alien, provide the "A" number from your Alien Registration Card (1 151 or 1551). 4. 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. Ss 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 2 INITIALS 6. | Beginning with your current residence(s) and working backwards, provide the date and address to each place where you have lived during the past five years. DATES ADDRESS Area Code (No., Street, Apt., City, State, Country & Zip Code) Telephone number From: —- To:----- 7. Marital Status: Single Married Legally Separated Divorced A. If married, give the name of your present spouse. B. List all former spouses: Rev. 7/00 3 INITIALS. CIVIL, CRIMINAL AND INVESTIGATORY PROCEEDINGS Prior to answering question # 8, 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, misdemeanors and disorderly conduct. 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; C. You completed a Pretrial Intervention Program (PIP) or equivalent diversionary program in other jurisdictions; D. You were not convicted; is You did not serve any time in prison or jail; or re The charges or offenses happened a long time ago. 2. Answer "NO" IF: 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 expungement or sealing order to this application. 8. Have you ever been arrested or charged with any crime or offense (other than a traffic violation) in the U.S. Virgin Islands or in any other jurisdiction? Yes No If yes, complete the following chart. NATURE OF CRIME DATE DISPOSITION Rev. 7/00 4 INITIALS 9. List the last three (3) jobs you have had beginning with the most recent and working backwards. Note with an asterisk(*) any employment where gaming was conducted on the premises. DATES From — To NAME OF EMPLOYER(S) MAILING ADDRESS TELEPHONE NUMBER POSITION HELD Description of duties REASON FOR LEAVING 10. List the name, address and telephone number of three references. (NO FAMILY MEMBER) NAME MAILING ADDRESS TELEPHONE NUMBER(S) (INCLUDE AREA CODE) Rev. 7/00 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.) Ll: _______ Tam the applicant who is submitting this application form. 2: I personally supplied the information contained in this form. I swear/affirm that the information contained in this form is true to the best of my knowledge and belief. I swear/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 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 U.S. 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. I, 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 , 20 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. ? 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