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CCC:CHERA. l REGISTRATION APPLICATION For: CASINO HOTEL EMPLOYEE CASINO HOTEL SECURITY EMPLOYEE CASINO SERVICE EMPLOYEE UNITED STATES 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 HOTEL EMPLOYEE REGISTRATION CHECKLIST  Casino Hotel Employee Registration Application. 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 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  Social Security Card  Naturalization Document or U.S. Passport  Offer letter VICCC use only U.S. VIRGIN ISLANDS CASINO CONTROL COMMISSION 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 OR REGISTERED. NAME: (last) (First) (Middle) ADDRESS: (Number and Street) Mailing (City) (State) (Zip Code) Phone No. (Day) 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 __ _ SIGN SIGN SIGN SIGN 1. 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 COURT CERTIFICATE NUMBER 3. If you are a legally authorized Permanent Resident Alien, provide the "A" number from your Alien Registration Card (1151 or I 551). 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. 5. 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. ADDRESS (No., Street, Apt., City, State, Country & Zip Code) DATES From: To: 7. Marital Status: Single Married Legally Separated A. If married, give the name of your present spouse. Rev. 7/00 B. List all former spouses: 3 Area Code Telephone number Divorced 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; 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: · 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 POSITION HELD Description of duties REASON FOR LEAVING From - To NAME OF EMPLOYER(S) MAILING ADDRESS TELEPHONE NUMBER 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 s INITIALS __________________ STATEMENT OF TRUTH STATE OF______________________ COUNTY OF ____________________ ) SS. )' Date: _____________ I _______________________________being duly sworn according to law deposes and says:: (Pr/111 Name) (Place your initials in appropriate response.) 1. 2. 3. 4. _____________________________ I am the applicant who is submitting this application form. _____________________________ I personally supplied the information contained in this form. ______________________________ I swear/affirn 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 thls ____ 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 voluntarily with full knowledge of its significance. (Print Name) SIGNATURE OF APPLICANT NOT ARY PUBLIC Commission Expiration Date Seal Date: _____________ Date of Birth: ________________ Social Security # ______________________________ SUBSCRIBED and SWORN to before me this _______ day of _________ 20_____ 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. I __________________________ have authorized the U. S. Virgin Islands Casino Control Commission (Signature of Applicant) NOTARY PUBLIC Commission Expiration Date Seal (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: _____________ Date of Birth: ________________ Social Security # ______________________________ SUBSCRIBED and sworn to before me this _______ day of _________ 20_____ SIGN