An applicant for License shall provide: Photo identification, birth certificate (long form), social security card and recent photograph to the Choctaw Gaming Commission.

Fingerprints will be processed by the Choctaw Gaming Commission.

All Transactions are Final. No Refunds.

Technology-related issues are outside the control of CGC. Therefore, CGC will not be responsible for any issues that arise from the malfunction or misuse of:

Websites, database, servers, APIs, network, hosting companies, software bugs, internet issues or other technological incidents that affect the availability, or functionality of CGC websites and application systems.

Notice Regarding False Statements

A false statement on any part of your license application may be grounds for denying a license or the suspension or revocation of a license. Also, you may be punished by fine or imprisonment (U.S. Code, title 18, section 1001).

Privacy Act Notice

In compliance with the Privacy Act of 1974, the following information is provided: Solicitation of the information on this form is authorized by 25 U.S.C. 2701 et seq. The purpose of the requested information is to determine the eligibility of individuals to be granted a gaming license. The information will be used by the Tribal gaming regulatory authorities and by the National Indian Gaming Commission (NIGC) members and staff who have need for the information in the performance of their official duties. The information may be disclosed by the Tribe or the NIGC to appropriate Federal, Tribal, State, local, or foreign law enforcement and regulatory agencies when relevant to civil, criminal or regulatory investigations or prosecutions or when pursuant to a requirement by a tribe or the NIGC in connection with the issuance, denial, or revocation of a gaming license, or investigations of activities while associated with a tribe or a gaming operation. Failure to consent to the disclosures indicated in this notice will result in a tribe's being unable to license you for a primary management official, key employee, or non-key employee position.

The disclosure of your Social Security Number (SSN) is voluntary. However, failure to supply a SSN may result in errors in processing your application.

Automatic Disqualification for Licenses and Work Permits

The Commission shall deny or revoke gaming licenses or work permits to persons or entities whose prior activities, criminal record, or records, habits and associations pose a threat to the public interest or to the effective regulation of gaming or create or enhance the dangers of unsuitable, unfair or illegal practices and activities in connection with gaming activities. All gaming licenses, primary management officials, and key employees shall be reviewed and if appropriate, renewed every (2) years with prompt notification to the National Indian Gaming Commission of renewals of licenses and other notifications as may be required by the applicable tribal-state compact. Without limiting the foregoing, the Commission must automatically deny or revoke gaming licenses or permits to persons:

Who have been convicted of a felony in any jurisdiction of any crime of moral turpitude.
Who have been convicted of a violation or conspiracy to violate the provisions of Title XV of the Choctaw Tribal Code or the Indian Gaming Regulatory Act or other federal laws relating to involvement in gaming without required licenses or willful evasion of gaming fees or taxes.
Having a notorious or unsavory reputation or association with such individuals which adversely affect public confidence and trust in gaming.
Whose license or work permit would violate conflict of interest rules in Section 15-1-4 of the Choctaw Tribal Code.
Who are under the age of 21 for gaming permit.
Who are under the age of 18 for non-gaming work permit (Authority- Section 15-1-17, Choctaw Tribal Code).

I hereby certify that I have read and understand the Notice Regarding False Statements, Privacy Act Notice, and the Automatic Disqualification for Licenses and Work Permits and that I am not automatically disqualified in accordance with those standards.

Applicant's Signature

Clear Signature

Today's Date

Personal Record

1. Personal Information

Name

First

Middle

Last

Alias

Nickname, maiden name, other name changes legal or otherwise

Email Address

Present Residence

Address Line 1

Address Line 2

City

State

Zip Code

Since (Date)

Present Business Address

Address Line 1

Address Line 2

City

State

Zip Code

Since (Date)

Occupation

Driver's License Number

State

Personal Phone Number

Business Phone Number

Date of Birth

Place of Birth

City, County, State, Country

Age

Social Security Number

Sex

Color of Eyes

Color of Hair

Weight

Height

Scars, tattoos, or distinguishing marks or characteristics

Bring a copy of birth certificate with you on your scheduled gaming appointment

Next of Kin or Person to be notified in case of an emergency:

Name

First

Last

Relationship

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Are you a citizen of the United States:

List all languages written or spoken:

Driver's License Information

If you have held a license in a different state during the previous five years, please enter details:

(Current) License Number

State

Do you have another license to add?

Enrollment Information

Are you an enrolled member of a federally recognized Indian Tribe?

Education Information

List in order of most recently attended:

School/College

City

State

Degree

Date From

Date To

Do you need to add another School/College?

Military Information

Are you currently active Military/Reserve?

Have you ever served in the military?

Arrests, Detentions, and Litigations

Include all arrest regardless of verdict of court proceedings.

Life History

A. Have you ever been arrested, fingerprinted, detained, charged, indicted, or convicted of any crime, either misdemeanor or felony?

B. Has a criminal indictment, information, or complaint ever been returned against you, but for which you were not arrested or in which you were named as an unindicted co-party?

C. Have you ever been subpoenaed to testify before a federal, state, or county grand jury, board or commission?

D. Have you ever had a civil or criminal record expunged or sealed by court order?

E. Have you ever received a pardon for any criminal offense?

F. Has any member of your immediate family or household ever been convicted of a felony?

G. Have you, as an individual, member of a partnership, or owner, director, or officer of a corporation, ever been a party to a lawsuit as either plaintiff or defendant (other than divorce)?

Current Residence

From

To

Address

Address Line 1

Address Line 2

City

State

Zip Code

Past Residences

How many past residences would you like to add?

Employment Information

Beginning with your current employment, list your work history, all businesses which you have been involved in, the percentage of ownership interest and/or all periods of employment for the past 5 years. Also, list all corporations, partnerships, or any other business ventures with which you have been associated as an officer, director, stockholder, or related capacity.

Are you currently employed?

May we contact your current supervisor?

May we contact your past supervisors?

Current/Past Employment 1

Company Name (Current/Past Employment 1)

Address (Current/Past Employment 1)

Address Line 1

Address Line 2

City

State

Zip Code

Title (Current/Past Employment 1)

Supervisor Name (Current/Past Employment 1)

Employed from (Current/Past Employment 1)

Employed to (Current/Past Employment 1)

% Ownership (Current/Past Employment 1)

Description of duties (Current/Past Employment 1)

Reason for leaving (Current/Past Employment 1)

Current/Past Employment 2

Company Name (Current/Past Employment 2)

Address (Current/Past Employment 2)

Address Line 1

Address Line 2

City

State

Zip Code

Title (Current/Past Employment 2)

Supervisor Name (Current/Past Employment 2)

Employed from (Current/Past Employment 2)

Employed to (Current/Past Employment 2)

% Ownership (Current/Past Employment 2)

Description of duties (Current/Past Employment 2)

Current/Past Employment 3

Company Name (Current/Past Employment 3)

Address (Current/Past Employment 3)

Address Line 1

Address Line 2

City

State

Zip Code

Title (Current/Past Employment 3)

Supervisor Name (Current/Past Employment 3)

Employed from (Current/Past Employment 3)

Employed to (Current/Past Employment 3)

% Ownership (Current/Past Employment 3)

Description of duties (Current/Past Employment 3)

Reason for leaving (Current/Past Employment 3)

Financial Interest

Have you ever had a financial interest in a gambling venture, including a racetrack, dog track, race horse, lottery, casino, bookmaking operation, or pari-mutual?

Refusal of Licenses

Have you ever been refused a gaming license or been a participant in any group which has been denied a gaming license?

Have you ever been refused a license for selling alcoholic beverages?

Safe Depository

Do you have a safe deposit box or such depository, access to any depository or do you use any other person’s depository?

Have you ever filed for or been granted a gaming license/work permit or been a participant in any group which has been issued a gaming license by any jurisdiction?

Do you have relatives associated with or employed in the gaming or liquor industry?

Character Reference:

List three (3) character references who have known you at least five years, including one personal reference who was acquainted during each period of residence listed. Do not include Tribal Chief or Tribal Council.

Character Reference 1

Name (Character Reference 1)

Relationship (Character Reference 1)

Address (Character Reference 1)

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number (Character Reference 1)

Years Known (Character Reference 1)

Character Reference 2

Name (Character Reference 2)

Relationship (Character Reference 2)

Address (Character Reference 2)

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number (Character Reference 2)

Years Known (Character Reference 2)

Character Reference 3

Name (Character Reference 3)

Relationship (Character Reference 3)

Address (Character Reference 3)

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number (Character Reference 2)

Years Known (Character Reference 3)

State of Licensure

Period Held

Nature of Disciplinary Action

Name of Regulatory Agency

Address

Address Line 1

Address Line 2

City

State

Zip Code

Have you had any previous relationships with Indian Tribes including ownership interest in the gaming manufacturing or liquor industries?

Have you had any previous business relationships and/or ownership in gaming industry including percentage ownership interest in those businesses?

Do you reside in the same household as someone who works for the Choctaw Gaming Commission? (Please do not list any associates employed by the Pearl River Resort.)

Choctaw Gaming Commission

Applicant’s Request to Release Information

To: Choctaw Gaming Commission

From: "Applicant's Name"

First

Last

I hereby authorize and request all persons to whom this is presented having information relating to or concerning me to furnish such information to a duly appointed agent of the Choctaw Gaming Commission, whether or not such information would be otherwise protected from disclosure by any constitutional, statutory, or common law or privilege.

I hereby authorize and request all persons to whom this request is presented having documents relating to or concerning me or the company to permit a duly appointed agent of the Choctaw Gaming Commission to review and copy any such documents whether or not such documents would otherwise be protected from disclosure by any constitutional, statutory, or common law or privilege.

If to whom this request is presented is a brokerage firm, bank, or savings and loan permit a duly appointed agent of the Choctaw Gaming Commission to review and obtain copies of any and all documents, records, or correspondence pertaining to me or the company, including but not limited to past loan information, notes co-signed by me, checking account records, saving deposit records, safe deposit box records, passbook, and general ledger folio sheets.

I do hereby make, constitute, and appoint any duly appointed agent of the Choctaw Gaming Commission as my true and lawful attorney in fact for me or the company in my name, place, stead, and on my behalf and for my use and benefit:
1. To request, review, copy, sign for, or otherwise act for investigative purposes with respect to documents and information in the possession of the person to whom this request is presented as I might;
2. To name the person or entity to whom this request is presented and insert that person's name in the appropriate location on this request;
3. To place the name of the Mississippi Gaming Commission agent presenting this request in the appropriate location on this request.

I grant to said attorney in fact full power and authority to do, take, and perform all and every act and thing whatsoever requisite, proper, or necessary to be done, in the exercise of any of the rights and powers herein granted, as fully to all intents and proposes as I might or could do if personally present, with full power of substitution or revocation, hereby ratifying and confirming all that said attorney in fact, or his substitute or substitutes, shall lawfully do or cause to be done by virtue of this power of attorney and the rights and powers herein granted.

This power of attorney shall end eighteen (18) months from its date of

I have filed with the Choctaw Gaming Commission a gaming license application. I understand that I am seeking the granting of a privilege and acknowledge that the burden of proving my qualifications for a favorable determination is at all times on me. I accept any risk of adverse public notice, embarrassment, criticism, or other actions of financial loss which may result from action with respect to this application.

I do, for myself, my heirs, executors, administrators, successors and assigns, hereby release, remise, and forever discharge the person to whom this request is presented, and his agents and employees from all and all manner of actions, causes of action, suits, debts, judgments, executions, claims, and demands whatsoever, known or unknown, in law or equity, which I ever had, now have, may have, or claim to have against the person to whom this request is presented or his agents or employees arising out of or by reason of complying with this request.

I agree to indemnify and hold harmless the person to whom this request is presented and his agents and employees from and against all claims, damages, losses, and expenses, including reasonable attorneys' fees arising out of or by reason of complying with this request.
A reproduction of this request by the Xerox or similar process shall be for all intents and purposes as valid as the original.

In witness whereof, I have executed this request on this

Today's Date

Applicant's Signature

Clear Signature

Applicant's Request to Release Information

Choctaw Gaming Commission

Release of All Claims

The undersigned has filed with the Choctaw Gaming Commission a gaming license application. In consideration of the assurance by the Commission that no vote on said "application" will be taken except after a deliberate, intensive and thorough investigation of the undersigned, including but not limited to background, associates, and finances, the undersigned does for myself, my heirs, executors, administrators, successors and assigns, hereby release, remise, and forever discharge the Mississippi Band of Choctaw Indians, and the Choctaw Gaming Commission, its members, agents, and employees, from any and all manner of actions, causes of action, suits, 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 and all said entities or individuals arising out of or by reason of the processing or investigation of or other action relating to the undersigned's "application.”

I, the undersigned, have read this release and understand all its terms. I execute it voluntarily and with full knowledge of its significance.

In witness whereof, I have executed this release on this

Today's Date

Applicant's Signature (copy)

Clear Signature

Release of All Claims

FOR OFFICE USE ONLY