USVI Public Records

Document text

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) RENEWAL PERSONAL IDSTORY 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. 3. Answer every question completely and truthfully. DO NOT LEA VE ANY BLANK SPACES. If a question 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. 7. Attach to this form complete copies of all federal, territorial, state and municipal income tax returns filed by 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 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, f"lll in the information below for each and every action. Separated, Annulled or Divorced 8/2002 PHD2-Renewal Date of Such Action Name and Address of Court and State of Issuance 3 Initials __ _ ___ 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 FROM: <MO/YR) 8/2002 PHD2-Renewal TO: <MO/YR) NAME AND ADDRESS OF SCHOOL, TRAINING PROGRAM, ETC. 4 DESCRIPTION OF LIST ANY DEGREE EDUCATIONAL OR CERTIFICATION PROGRAM ATTAINED Initials __ _ 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 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. 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 GAMBL_ING APPROVAL 8/2002 PHD2-Renewal POSITION DATE OF SOUGHT OR APPLICATION HELD NAME AND ADDRESS DISPOSITION IF ISSUED, GIVE OF LICENSING (GRANTED, APPROPRIATE AGENCY DENIED OR NUMBERS (INCLUDE COUNTRY, PENDING) STATE, COUNT OR MUNICIPALITY) 5 Initials __ _ 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 Hyes, 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." C. "Offense" includes all ctjmes, 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: 8/2002 PHD2-Renewal 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. 6 Initials __ _ I I 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 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 Hyes, complete the following chart: NATURE OF DATE OF NAME AND ADDRESS OF DISPOSITION SENTENCE CHARGE OR CHARGE OR LAW ENFORCE:MENT (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 Hyes, complete the following chart: NAME AND ADDRESS OF COURT OR OTHER AGENCY 8/2002 PHD2-Renewal NATURE OF WAS PROCEEDINGS OR TESTIMONY INVESTIGATION GIVEN 7 DATE ON APPROXIMATE WHICH TIME PERIOD TESTIMONY OF WAS GIVEN INVESTIGATION Initials __ _ . 13. a) Within the past four (4) years have you been a party to a 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 Hyes 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 PHD2-Renewal 8 Initials __ _ 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 H 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/YR <MO/YR \ 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. H yes, also complete the following chart: DATE FILED 8/2002 PHD2-Renewal DOCKET NUMBER NAME & ADDRESS OF COURT 9 NAME AND ADDRESS OF TRUSTEE Initials --- 17. Within the past four (4) years has any business entity in which you held 10% or greater ownership (other than ownership ofstock 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 Hyes, complete the following chart: DATE DOCKET NAME & ADDRESS OF NAME & ADDRESS OF NAME & ADDRESS FILED NUMBER COURT FILING PARTY 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 H yes, complete the following chart: DATE FILED 8/2002 PHD2-Renewal DOCKET NAME & ADDRESS OF NUMBER COURT 10 NATURE OF AMOUNT OF NAME& OBLIGATION OBLIGATION ADDRESS OF HOLDER OF OBLIGATION 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 Hyes 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. H 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. Subscribed and sworn to before me this …††‡day of††ˆ†- -††- Notary Public Commission Expiration Date SEAL 8/2002 PHD2-Renewal By 12 Signature Applicant Entity Title Initials --- SIGN