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PERSONAL HISTORY DISCLOSURE FORM 2 RENEWAL LE ET MT OO cae i a MENT 6 ex <Ces Vre gad EW & ——--. \ & xe Qf A Ses OM My << YY TES VIR > si, er ae a UNITED STATES VIRGIN ISLANDS 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) RENEWAL PERSONAL HISTORY DISCLOSURE FORM 2 APPLICATION INSTRUCTIONS 1. You are to complete this application if you are: a. An applicant for a renewal 3-year casino employee license; or b. An applicant for a renewal 3-year gaming school employee license; or c. Directed to do so by the Casino Control Commission (Commission). 2. Read this entire form carefully before answering any of the questions. rH Answer every question completely and truthfully. DO NOT LEAVE ANY BLANK SPACES. If a questior does not apply to you, indicate “Does not apply” in response to that question. If there is nothing to disclose to a particular question, state “None” in response to that question. 4, All entries on this form, except signature, must be typed or block printed in black ink. If your application not legible, it will not be accepted. 5. Initial each page of this form in the space provided after you have checked your answers and are sure they are complete and correct. 6. Sign the License Conditions, Release Authorization and Release of all Claims Forms in the presence of a Notary Public. ys Attach to this form complete copies of all federal, territorial, state and municipal income tax returns filed t you and your spouse for the last three (3) years. 8. Submit an original and one (1) copy of this entire form to the U.S. Virgin Islands Casino Control Commission. 9. Once filed, you may not withdraw your application without the permission of the U.S. Virgin Islands Casino Control Commission. 10. We recommend that you keep a copy of your completed application for your records. 8/2002 1 Initials PHD2-Renewal U.S. VIRGIN ISLANDS CASINO CONTROL COMMISSION (print or type all answers) Personal History Disclosure Form 2 Renewal OCCUPATION SIGNATURE OF EMPLOYER SIGNATURE OF APPLICANT i 2. NAME: (Last) (First) (Middle) Mailing Address: (City) (State) (Zip Code) Daytime Phone No. Physical Address (Home): (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: 1. Have you previously 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 OF DISPOSITION IF ISSUED, GIVE PERMIT, APPROVAL OR | APPLICATION (GRANTED, PENDING, APPROPRIATE REGISTRATION DENIED) NUMBER(S) PREVIOUSLY APPLIED FOR 8/2002 2 Initials PHD2-Renewal 2. 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: 3. 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 four years. TELEPHONE DATES ADDRESS NUMBER (No., Street, Apt., City, State, Country & Zip Code) FROM: TO: (MO/YR) (MO/YR) 4. Circle your current marital status: Single Engaged Married Legally Separated Divorced Widowed 5. Give the name and current address of your present spouse: 6. If you have been separated, annulled or divorced, fill in the information below for each and every action. Separated, Annulled or Divorced Date of Such Name and Address of Court and State of Issuance Action 8/2002 3 Initials PHD2-Renewal 7. 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 within the last four (4) years. Be sure to include participation in certified Territorial casino gaming 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) 8/2002 4 Initials PHD2-Renewal 8. Provide the information listed below as to each place in which you have been employed for the past four (4) 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, Internet gaming, horse racing or parimutuel operation, lottery, sports betting, etc.) DATES FROM: TO: (MO/YR MO/YR NAME, MAILING ADDRESS TITLE, POSITION HELD AND PHONE NUMBER OF AND DESCRIPTION OF EMPLOYER(S). INCLUDE DUTIES NAME OF IMMEDIATE SUPERVISOR. REASON FOR LEAVING 9. Within the past four (4) years have you applied in any other jurisdiction for a license, permit or other authorization to participate in a lawful gambling operation (including casino gaming, horse racing, parimutuel operation, lottery, sports betting, etc.?) 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) 8/2002 5 Initials PHD2-Renewal 10. Within the past four (4) years have you had any license, permit or certificate denied, suspended or revoked by any governmental agency? (Do not include driver’s license.) Yes No Ifyes, 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 Question #11 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.” Cc. “Offense” includes all crimes, felonies, 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; B. 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. 8/2002 PHD2-Renewal 6 Initials Zs 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 expungment or sealing order to this application. 11. Within the past four (4) years, have you been arrested or charged with any crime or offense (other than a traffic violation) in this Territory or anywhere else? Yes No If yes, complete the following chart: NATURE OF DATE OF NAME AND ADDRESS OF DISPOSITION SENTENCE CHARGE OR CHARGE OR LAW ENFORCEMENT (CONVICTED, ARREST ARREST AGENCY OR COURT ACQUITTED, INVOLVED DISMISSED, PENDING, PARDONED, ETC.) 12. Within the past four (4) years, have you 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 If yes, complete the following chart: NAME AND ADDRESS OF NATURE OF WAS DATE ON APPROXIMATE COURT OR OTHER PROCEEDINGS OR TESTIMONY WHICH TIME PERIOD AGENCY INVESTIGATION GIVEN TESTIMONY OF 8/2002 7 Initials PHD2-Renewal WAS GIVEN | INVESTIGATION 13. a) Within the past four (4) years have you been a party toa lawsuit? (Include matrimonial matters, negligence matters, auto accident matters, contract matters, collection matters, debt matters, etc.) Yes__No b) Within the past four (4) years have you 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 14. During the past four (4) years, have you or your spouse held a ten percent (10%) or more ownership interest in or been a director, officer or principal employee of any corporation, partnership, sole proprietorship, or other business entity that has held a foreign bank account or that has had the authority to control disbursements from a foreign bank account? Yes No . Indicate if self or spouse. 8/2002 8 Initials PHD2-Renewal 15. Within the past four (4) 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 FROM: TO: (MO/YR (MO/YR NAME(S) AND ADDRESS(ES) OF BUSINESS(ES) CURRENT STATUS OF BUSINESS(ES) % OF INTEREST HELD BY YOU NAME(S) OF OTHER OWNER(S) 16. Within the past four (4) years have you personally been adjudicated bankrupt or filed a petition for any type of bankruptcy or insolvency under any bankruptcy insolvency law? Yes No If yes, attach a copy of the bankruptcy petition and discharge, if granted. If yes, also complete the following chart: DATE FILED DOCKET NUMBER NAME & ADDRESS OF | NAME AND ADDRESS COURT OF TRUSTEE 8/2002 9 Initials PHD2-Renewal 17. Within the past four (4) years 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 been adjudicated bankrupt or filed a petition for any type of bankruptcy or insolvency under any bankruptcy or insolvency law? __ Yes ___No If yes, complete the following chart: DATE FILED DOCKET NAME & ADDRESS OF NUMBER COURT NAME & ADDRESS OF FILING PARTY NAME & ADDRESS OF TRUSTEE 18. Within the past four (4) years have your wages, earnings, or other income been subject to garnishment, attachment, charging order, voluntary wage execution or the like? __ Yes No If yes, complete the following chart: DATE FILED DOCKET NUMBER NAME & ADDRESS OF | NATURE OF AMOUNT OF COURT OBLIGATION | OBLIGATION NAME & ADDRESS OF HOLDER OF OBLIGATION 8/2002 PHD2-Renewal 10 Initials 19. 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. 20. State when you filed your last Federal Income Tax Return Form 1040, to what Internal Revenue Service Center it was sent and the tax period covered. Date Filed: Period Covered: IRS Office Location: Attach to the back of this form and label as Exhibit 20 complete copies of all federal, state, territorial and municipal Income Tax Returns filed within the past three (3) years. 8/2002 PHD2-Renewal 11 Initials LICENSE APPLICATION CONDITIONS By the signing of this application, the applicant entity acknowledges that the laws of the Virgin Islands and the United States, as applicable, shall apply to the conduct of its operations and that the applicant shall comply with all rules and regulations promulgated by the Commission. The applicant entity also acknowledges that, if a license be granted, it will become the duty of the applicant/licensee to file with the U.S. Virgin Islands Casino Control Commission (“Commission”) such reports and financial data as may be required by Territorial Statute or by such rules and regulations as the Commission has adopted or may hereafter adopt, and to make such payments and/or fees as may be required by law. The aforementioned duty shall continue for the entire term (duration) of the license. If the applicant/licensee fails to abide by these requirements, the applicant/licensee shall incur the penalties set forth in the U.S Virgin Islands Code or in such rules and regulations as the Commission has adopted or may hereafter adopt. Applicant entity verifies that all exhibits, statements, reports, papers, data, etc. submitted pursuant to this application are true, complete and current. The applicant entity additionally agrees to THEREAFTER provide the Commission with full description of any significant operational change in any of the aforementioned exhibits, statements, reports, papers, data, etc. as said change occurs. Applicant entity hereby consents to all inspections, searches and seizures and the supplying of handwriting exemplars as authorized by 32 VIC 432(c). Applicant entity agrees that any license which may hereafter be granted to said individual or entity is predicated upon the statements and answers herein contained, which may be subject to verification by the Division of Gaming Enforcement or the Commission. Applicant entity verifies that the above statements are true and correct to the best of his/her knowledge and belief, and that this application is executed with the knowledge that any misrepresentation or failure to reveal information requested may be deemed sufficient cause for the refusal to issue, or revocation of, a license. Further, that said applicant entity is voluntarily submitting this statement and understands that misleading statements may subject applicant entity to criminal or other sanctions or punishment. I/We have read the application, attached instructions and above paragraphs, and agree to the conditions as set forth. Signature Subscribed and sworn to before me this day of ’ - By Applicant Entity Notary Public Title Commission Expiration Date SEAL 8/2002 12 Initials PHD2-Renewal RELEASE AUTHORIZATION TO: All Courts, Probation Departments, Selective Service Boards, Employers, Educational Institutions, Banks, Credit Unions, Other Financial Institutions, Credit Reporting Agencies, Law Enforcement Agencies, Regulatory Agencies and all Governmental Agencies, Territorial, Federal, State and Local, without exception, both foreign and domestic. Applicant (Print Name) of Current Address have authorized the U.S. Virgin Islands Casino Control Commission, and/or the Division of Gaming Enforcement, U.S. Virgin Islands Department of Justice, to conduct an investigation into the background of the said Applicant. Therefore, you are hereby authorized to release any and all information pertaining to the said applicant, documentary or otherwise, as requested by any appropriate employee, agent or representative of the United States Virgin Islands Casino Control Commission and/or the Division of Gaming Enforcement, United States Virgin Islands Department of Justice. 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: (Applicant’s Signature) Subscribed and sworn to before me on this day of , 20 NOTARY PUBLIC Commission Expiration Date SEAL Revised August 29, 2006 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, know 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 voluntarily with full knowledge of its significance. Dated: SIGNATURE OF APPLICANT SUBSCRIBED AND SWORN TO BEFORE ME THIS DAY OF 9 . Commission Expiration Date NOTARY PUBLIC SEAL 8/2002 14 Initials PHD2-Renewal