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' . CCC:PIIDf2 PERSONAL HISTORY DISCLOSURE FORM2 UNITED Sl .. ATES VIRGIN ISLANDS Rev. 7/00 Virgin Islands Casino Control Commission 3005 Orange Grove Christiansted, VI 00820-3005 (340) 718-3616 ext. 240 • (340) 718-3136 fax info@casinocontrolcommission.vi CASINO EMPLOYEE LICENSE APPLICANT CHECKLIST  Personal History Disclosure Form 2. Applicant must answer every question completely  Statement of Truth, Release of all Claims, and Release Authorization must be notarized THE FOLLOWING DOCUMENTATION ARE REQUIRED FOR INITIAL APPLICATION  Fingerprint card  VIPD Background check  2 passport size pictures  2 Government issued I.D. (i.e., V.I. Driver’s license, Passport and/or Voter’s I.D.)  Birth Certificate  Naturalization Document or U.S. Passport  Offer letter  Tax documents (last 3 years)  Social Security Card  High School Diploma THE FOLLOWING DOCUMENTATION ARE REQUIRED FOR RENEWAL APPLICATION  Personal History Disclosure Form 2 – Renewal. Applicant must answer every question completely  Fingerprint card  Background check  2 passport size pictures  Tax documents (last 3 years) PERSONAL HISTORY DISCLOSURE FORM 2 APPLICATION INSTRUCTIONS 1. 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). 2. Read this entire form carefully before answering any of the questions. 3. Answer every question completely and truthfully. DO NOT LEA VE ANY BLA.11{K SPACES. If a 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 tbat question. 4. All entries on this form, except signature, must be typed or block printed in ulack ink. If your application is 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 Statement of Truth, the Release Authoriwtion and Release ofa ll Claims in the presence of a Notary Public. 7. Attach to this form a copy of your birth certifinte. 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. 8. Attach to this form a copy of your Social Security Card aud a copy of a government-issued I.D. 9. All persons completing this application form must be fingerprinted. Appropriate fingerprint cards must accompany this application. 10. Submit an original and one (1) copy of this entire form to the U.S. Virgin Islands Casino Control Commission. 11. Once filed, you may not withdraw your application without the permission of the U.S. Virgin Islands Casino Control Commission. 12. We recommend that you keep a copy of your completed application for your records. 13. IMPORTANf! Staple two recent photographs within the box. Print name on rear of photographs. 14. 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 Initials __ _ ' . OCCUPATION APPLIED FOR: U.S. VIRGIN ISLANDS CASINO CONTROL COMJ\1ISSION (print or type all answers) SIGNATURE OF EMPLOYER VI CCC Use Only SIGNATURE OF APPLICANT EMPLOYER SIGNATURE ABOVE CERTTFIES THAT THE APPLICANT NAMED HEREIN HAS BEEN OFFERED A POSillON AND HAS OR WILL BE TRAINED IN THE occur A TION IND I CA TED AND WILL BE EMPLOYED IF LICENSED. 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 BIJlTH: Maiden Name: Height Weight Si>cial Security #: ALIASES OR 1'.'ICKNAMES: DRIVER'S LICENSE INFORMATION STATE: NUMBER: PLEASE 0-IECK (for statistical purposes only) SEX RACE Male Female Caucasian 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 lnitials --- SIGN SIGN SIGN SIGN J. Have you been known by any name or names other than as listed on previous page? If yes, 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): _____________ _ 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: 3. If you arc a naturalized citizen, provide the following information: PETITION NUMBER DATE GRANTED COURT CITY/STATE OF COlffiT CERTrFICATE NUMBER 4. If you arc a legally authorized Permanent Resident Alien, provide the "A" number from your AJicn Registration Card (1151 or I 551). -------------- 5. If you do not have an Alien Registration Card but arc an alien authorized to be employed in the United States, please provide the "A" number from that autbori1..ation. 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 rcsidence(s) and working backwards, provide the following information with respect to each place where you have Jived during the past five years. TELEPHONE DATES ADDRESS NUMBER (No., Street, Apt., City, State, Country & Zip Code) FROM: TO: (MO/YR) (MO!YR) Rev. 7/00 4 fnitials 7. FAMJLYDATA Circle your current marital Status: Single Married Legally Separated A. Give the name of your present spouse: ______________ _ C. List all former spouses: __________ _ MILITARY SERVICE DATA Divorced 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: FROM: TO: TO: 9. 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 bad 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 If yes, give details of the charge(s) and their disposition(s). NOTE: Attach to this form a copy of your military record (00214). 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 __ __ EMPLOYMENT AND LICENSING DATA 12. Provide the information listed belo w 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 AND PHONE NUMBER OF AND DESCRIPTION OF LEAVING EMPLOYER(S). INCLUDE DUTIES FROM: TO: NAME OF IMMEDIATE (MO/YR MO/YR SUPERVISOR Rev. 7/00 7 Initials 13. 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 No. If yes, complete the following parimutuel operation, lottery, sports betting, etc.?) __ Yes chart: TYPE OF POSffiON DATE OF NAME AND ADDRESS DISPOSffiON IF ISSUED, GIVE GAMBLING SOUGHT OR APPLICATION OF LICENSING (GRANTED, APPROPRIATE APPROVAL HELD AGENCY DENIED OR .l\ruMBERS (INCLUDE COUNTRY, PENDING) STATE, COUNT OR MUNICIPALITY) 15. Have you ever bad 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, CERTIJ?ICATE AGENCY REVOCATION SUSPENSION OR REVOCATION Rev. 7/00 8 Initials --- _ _ CIVIL, CRIMJNAL 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 oftbe 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 alJ 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 (PJP) 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" IF: Rev. 7/00 A. The records relating to the arrest or charges have been expunged or sealed by court order; AND 13. You attach a copy of the expungment or sealing order to this application. 9 Initials __ _ 16. Have you ever been arrested or charged with any crime or offense (other than a traffic violation) iu this Territory or anywhere else? __ Yes __ No If ycs, complete the following chart: NATURE OF DATE OF NAME AND ADDRESS OR DISPOSITION SENTENCED CHARGE OR CHARGE OR LAW ENFORCEMENr (CONVICTED, ARREST ARREST AGENCY OR COURT ACQUITTED, INVOLVED DISMISSED, PENDING, PARDONED, ETC.) 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 iu 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 \VIIlCH TI ME PERIOD AGENCY INVESTIGATION GIVEN TESTIMONY OF WAS GIVEN INVESTIGATION Rev. 7/00 10 lnitials 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 OTIIBR 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 auy business(cs)? (Do not include publicly traded corporations in which you owned stock.) __ Yes __ No If yes, beginning witb tbe most recent and working backwards, provide the following information with regard to all busincss(C3) 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/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? __ Yes __ No If yes, attach a copy of the bankruptcy petition and discharge if granted. Ifycs, also complete the following chart: DATE FILED DOCKET NUMilER 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 au 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 Ifycs, complete the following chart: DATE DOCKET NAME & ADDmrss OF NAME & ADDRESS OF NAME & ADDRESS FILED NUMBER COURT FILING PARTY OF TRUSTEE Rev. 7/00 12 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 FILED NUMBER COURT OBLIGATION OBLIGATION 23. Do you have any bank accounts or safe deposit boxes in your name? Yes Do you have access to the funds in any other bank accounts or safe deposit boxes? If ycs to either question, complete the following chart: NAME & ADDRESS OF NAME(S) IN WHCH TYPE OF ACCOUNT, BANK ACCOUNT(S) OR SAFE (SA VIN GS, CHECKING, DEPOSIT BOX(ES) HELD SAFE DEPOSIT, ETC.) NAME& ADDRESS OF HOLDER OF OBLIGATION No Yes No ACCOUNT NO. OR SAFE DEPOSIT BOX NO. Rev. 7/00 13 Initials __ _ __ __ 24. Provide the 11ames and other inforn'lation requested of three (3) references over the age of 18 who have known you for at least one year and can aHest to your good character, reputation and business ability. No person cau be a reference who is a member of your family. (Spouse, parents, grandparents, cbildren, grandcbildren, 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 balf-blood, by marriage, adoption or natural reh,tionship.) REFERENCE ONE 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 rcfe,·cnce? __ _ Telephone No.: ____________ _ REFERENCE Tl-IllliE 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 im01ediately 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. IDENTIBY ALL ANSWERS BY ORIGINAL QUESTION NUMBERS Rev. 7/00 15 Initials Date: STATEMENT OF TRUTH ) SS. ) -------------' being duly sworn according to law deposes and says: (Print Name) (Place your initials in appropriate response.) 1. 2. " .). 4. ----- f am the applicant who is submitting this application form. 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. l swear/affinn 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 Seal SIGN 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 Bi.tih: -------- Social Security#: _______ _ SUBSCRIBED and SWORN to before me this __ day of ______ , 20 __ NOTARY PUBLIC Commission Expiration Date :;_:· Seal SIGN 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. _______________ 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 othen¥ise, as requested by any employee or agent of the U.S. Virgin Islands Casino Control Conunission 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. Thjs 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: Date of Birth: (Signature of Applicant) Social Security#: _______ _ SUBSCRIBED and sworn to before me this ___ day of _______ , 20 __ NOTARY PUBLIC Commission Expiration Date Seal SIGN