YOCHA DEHE TRIBAL GAMING AGENCY GAMING LICENSE APPLICATION POSITION APPLIED FOR: Name: Social Security Number - - Last First Middle Other Names/Nicknames Used (Oral or Written, Including Maiden Name): Date of Birth / / Place of Birth: Mother s Maiden Name: Race Height Weight Eyes Hair Number Street Apt.. City County State Zip Code Mailing Address if different from above: P.O. Box City State Zip Code List any adults (18 and older) that live with you: If you need more room, please attach an additional sheet. Name (First and Last) Relationship Employer/Occupation Home Phone: ( ) Business /Cell ( ) Gender: Male Female List any scars, tattoos or other distinguishing marks: Citizenship: If Other Than United States: Alien Resident Number: Exp Date: If offered a position, will you be able to provide identification and proof of eligibility to work in the United States? Yes Are you a Tribal Citizen/Member? Yes If yes: Tribal Affiliation: Enrollment #: Have you been employed, or applied for employment at Cache Creek Casino Resort or with Yocha Dehe Wintun Nation? Yes If yes, please explain: Language, other than English, in which you are fluent: Read Write If you are using a translator to complete your Tribal Gaming Application, the following is required. Printed Name of Translator Signature of Translator Date Relationship Revised on: 4/27/2016 1
Do you possess a valid California Drivers License? Yes If Yes: License #: Exp Date: If, please explain: Do you possess a valid California Identification Card? Yes If Yes: I.D. #: Exp Date: Do you currently have any family members who work at Cache Creek Casino Resort or the Yocha Dehe Wintun Nation? Yes If yes, provide name, relationship and position held: If you need more room, please attach an additional sheet Name (First and Last) Relationship Position. PREVIOUS ADDRESSES: Begin with your most recent address. List all residences within the past ten years. If you need more room, please attach an additional sheet. Dates From - To Residence Address Number Street Apt # City County State Zip Number Street Apt # City County State Zip Number Street Apt # City County State Zip Number Street Apt # City County State Zip EDUCATION/TRAINING/SPECIAL QUALIFICATIONS Highest Grade Completed: I possess a: High School Diploma GED Certificate or High School Proficiency High School: Name City State College/University/Trade School or Special Training Course of Study/Major Date Degree or Certificate Awarded Type of Degree or Certificate Revised on: 4/27/2016 2
EMPLOYMENT HISTORY/WORK EXPERIENCE/INTERNSHIP Begin with your most recent experience and list all positions within the past five years, including ownership interests in those businesses. Complete this section even if you attach a resume. Complete ALL sections. Revised on: 4/27/2016 3
EMPLOYMENT HISTORY/WORK EXPERIENCE (Continued) Revised on: 4/27/2016 4
EMPLOYMENT HISTORY/WORK EXPERIENCE (Continued) Describe any existing or previous business relationships with Indian tribes, including ownership interests in those businesses: Describe any existing or previous business relationships with the gaming industry generally, including ownership interests in those businesses: List name and address of any licensing or regulatory agency with which you have filed an application for a gaming license or permit, whether or not such license or permit was granted: Agency Agency Address/City/State/Zip Address/City/State/Zip List the name and address of any licensing or regulatory agency with which you have filed an application for an occupational license or permit, whether or not such license or permit was granted: Agency Agency Address/City/State/Zip Address/City/State/Zip Have you ever had a gaming license/permit/occupational license: Suspended Yes Revoked Yes Denied Yes If you answered yes to any of the above, explain: MILITARY SERVICE DD214 Form Is Required Service Branch: Dates of Service: Rank: Character of Service/Discharge: If other than honorable, please explain: Are you currently serving in any Military Reserve Program? Yes Revised on: 4/27/2016 5
PERSONAL REFERENCES - Do not use relatives or significant others. During the course of the background investigation, persons who know you will be asked to comment on your suitability for employment with Cache Creek Casino Resort or Yocha Dehe Wintun Nation. Include one reference that was acquainted with you during each period of residence. List the names and current home mailing address, as well as phone numbers for five personal references. DO NOT USE BUSINESS INFORMATION. 1. Name: Phone: ( ) 2. Name: Phone: ( ) 3. Name: Phone: ( ) 4. Name: Phone: ( ) 5. Name: Phone: ( ) This Section for Investigator Use Only: Revised on: 4/27/2016 6
CRIMINAL HISTORY/SECURITY DISCLOSURE HAVE YOU EVER BEEN ARRESTED FOR A FELONY OR MISDEMEANOR CRIME? YES NO HAVE YOU EVER BEEN ARRESTED FOR A FELONY OR MISDEMEANOR CRIME AS A JUVENILE? YES NO For each felony for which there was an arrest or there is an ongoing prosecution or a conviction, you must list the date of arrest, charge, name and address of the court involved, date of disposition and case disposition: Date of Arrest Charge Name & Address of Court Date of Disposition Disposition For each misdemeanor for which there was an arrest or there is an ongoing prosecution or a conviction, within 10 years of the date of application, you must list the date of arrest, charge, name and address of the court involved, date of disposition and case disposition: Date of Arrest Charge Name & Address of Court Date of Disposition Disposition For each Felony or Misdemeanor for which there was an arrest, an ongoing prosecution or a conviction, you must provide disposition paperwork. This can be attained from the courthouse where the case was adjudicated or is currently being adjudicated. You will not be processed without the required documents. CERTIFICATION I certify that the information given by me in this application is true and complete in all respects to the best of my knowledge and belief, and I agree that any false statements or omissions shall be considered sufficient cause for disqualification from further consideration or dismissal if I am ultimately hired. I am aware that the purpose of this background investigation is to determine my suitability for a tribal gaming license. I understand that the Tribal Gaming Agency as part of determining my suitability for licensing will request my consumer credit report. My signature below authorizes the Tribal Gaming Agency to request my credit report for such purposes. I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between Cache Creek Casino Resort/Yocha Dehe Wintun Nation, myself for either employment or for the providing of any benefit. promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon Cache Creek Casino Resort/ Yocha Dehe Wintun Nation unless made in writing by an authorized person. I have read, understand and agree to the information noted above: Applicant s Signature Date Revised on: 4/27/2016 7
PRIVACY ACT OF 1974 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 or 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. FINGERPRINT AUTHORIZATION I understand that I must have my fingerprints taken by the Yocha Dehe Tribal Gaming Agency. I also understand that these prints will be submitted to the F.B.I. and/or California Department of Justice for the purposes of conducting an investigation into my background. DUTY TO REPORT INFORMATION TO TGA As a TGA applicant/licensee, I agree to keep the TGA informed of any and all changes in any information supplied to the Tribal Gaming Agency on my background investigation. This includes name, address and phone number changes and any criminal charges and conviction(s) occurring after the submission of this application. Reporting criminal charges includes all misdemeanors and felonies. I have read, understand and acknowledge all the information noted above: Date Applicant s Name (Please Print) Applicant s Signature Revised on: 4/27/2016 8
YOCHA DEHE TRIBAL GAMING AGENCY RELEASE AUTHORIZATION TO: All courts, probation departments, selective service boards, banks, employers, past employers, education institutions, and all governmental agencies Federal, State and local, without exception. I,, have authorized the Yocha Dehe Wintun Nation and the Yocha Dehe Tribal Gaming Commission and their agents to conduct a full investigation into my background. 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 Yocha Dehe Tribal Gaming Agency. This authorization shall supersede and countermand any prior requests or any authorization to the contrary. This authorization also releases you from any type of action for releasing the information to the Yocha Dehe Tribal Gaming Agency. A photostat copy of this authorization will be considered as effective and valid as the original. Date Applicant s Name (Please Print) Applicant s Signature Revised on: 4/27/2016 9