YSLETA DEL SUR

PUEBLO TRIBAL

GAMING

COMMISSION

GAMING LICENSE APPLICATION

THE AUTHORIZATION AND RELEASE OF INFORMATION FORM ON THE FOLLOWING PAGE IS TO BE COMPLETED IMMEDIATELY.

ALL APPLICANTS MUST COMPLETE THIS FORM BEFORE ISSUANCE OF A LICENSE. UPON RECEIPT OF THE AUTHORIZATION AND RELEASE OF INFORMATION FORM AND A NEGATIVE FINDING FROM THE CURSORY BACKGROUND, A TEMPORARY GAMING LICENSE MAY BE ISSUED WITHIN 1-5 BUSINESS DAYS. AND UPON COMPLETION OF THE FULL BACKGROUND AND UPON NEGATIVE FINDINGS, A GAMING LICENSE MAY BE ISSUED BY YDS PUEBLO GAMING COMMISSION.

The requested information in this document is to be filled out within one week of receiving it.

AUTHORIZATION FOR RELEASE OF INFORMATION

This release of information constitutes my consent and authorization to the agencies or representatives identified to furnish YSLETA DEL SUR PUEBLO GAMING COMISSION and MAXIMUM REPORTS, INC., and/or its representative’s permission and authority to conduct a background check. I understand and consent to an investigation that is limited to criminal and civil record history information, motor vehicle driving history, human services inquiry for domestic violence, child abuse and neglect information, employment verification, educational verification, professional licensing, personal and professional references, and credit reports whether or not such information would otherwise be protected from disclosure by any constitutional, statutory or common law privilege.

I authorize the custodians of such records and sources of information to release the information, including permitting the review and copying of all documents, records or correspondence pertaining to me, to the representatives YSLETA DEL SUR PUEBLO GAMING COMISSION and MAXIMUM REPORTS, INC., regardless of any previous agreement to the contrary.

I agree to accept all risks of adverse public notice, embarrassment, criticism, or financial loss that may result from use of information obtained in connection with a background investigation for the purpose listed in this document.

I agree to indemnify and hold harmless any person to whom this is lawfully presented and their agent and employees from and against all claims, damages, losses, and expenses, including reasonable attorney(s) fees, arising out or by reason of complying with this request.

Applicant Full Name (Please Print)

Tribal Affliliation (If Applicable)

Maiden Name (If Applicable)

Social Security Number

Driver License Number

Date of Birth

Month

Day

Year

Address

City

State

Zip

Date

Month

Day

Year

Signature

NOTICES FOR LICENSING APPLICATION:

The Gaming Commission (“Commission”) shall obtain sufficient information and identification from the applicant to permit a thorough background investigation of the applicant.

The applicant shall provide to the Commission a written release authorizing the Commission or its agents, to conduct a background investigation. A release is attached at the end of this application.

Prior to providing such release. Employees, Key Employees and Primary Management Officials should thoroughly read the Privacy Act of 1974, below.

In compliance with the Privacy Act of 1974, the following information is provided:

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 who have need for the information in the performance of their official duties.

The information may be disclosed by the Tribe 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 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 being unable to license you for a Primary Management Official or Key Employee position. 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. You may also be punished by fine or imprisonment (18 U.S.C. Section 1001). See also, Subsection (m)(2) and Part V Section 23 (1) (b) of the Tribal Gaming Ordinance. The

tribal gaming agency and its agents shall keep confidential the identity of each person interviewed in the course of the investigation.

Penalties for Inaccurate or False Statements

In addition to the above, should applicant provide false or inaccurate statements anywhere within the application knowingly or through omission or mistake, applicants license may be revoked or denied. And should any applicable civil or criminal penalties be triggered, the gaming

commission shall forward this information to the appropriate tribal, federal, and state agencies and or law enforcement entities.

Disclosure Information

The information you provide is for the purpose of investigating you for a gaming license.

The information will be protected from unauthorized disclosure. The collection, maintenance, and disclosure of the background investigative information will be protected from unauthorized disclosure in accordance with Ysleta del Sur Pueblo Gaming Commission’s privacy procedures.

The information you provide on this form, and information collected during an investigation, may be disclosed without your consent by an agency maintaining the information in a system of records as permitted by the Privacy Act [5 U.S.C. 552a(b)] in addition to the Ysleta del Sur Pueblo Gaming Commission’s privacy procedures. You will not receive prior notice of such disclosures under routine use.

I have read the preceding instructions and I understand that if I withhold, misrepresent, or falsify information on this form, I am subject to the penalties for inaccurate or false statements (identified in the instructions), and the denial or revocation of a license.

YES

Ysleta Del Sur Pueblo Tribal Gaming Commission

122 S Old South Pueblo, Ysleta Del Sur Pueblo, Texas, 79907

Gaming License Application

PERSONAL INFORMATION

FULL NAME

DATE

OTHER NAMES USED, IF ANY

DATE OF BIRTH

PRONOUNS ADDRESSED BY

ADDRESS

CITY

STATE

ZIP

E-MAIL

PHONE

SOCIAL SECURITY NUMBER (SSN)

DRIVER LICENSE NUMBER

ISSUING STATE FOR DRIVER'S LICENSE

POSITION APPLIED FOR OR CURRENTLY HELD

ARE YOU A U.S. CITIZEN?

YES

IF NO, ARE YOU ALLOWED TO WORK IN THE U.S.

YES

PLEASE, PROVIDE DOCUMENTATION AND ATTACH TO END OF APPLICATION

PLACE OF BIRTH

HAVE YOU EVER WORKED FOR THIS EMPLOYER?

YES

IF YES, PROVIDE THE START AND END DATES

LIST ALL LANGUAGES SPOKEN OR WRITTEN

PLEASE LIST ALL BUSINESSES OWNED IF ANY

ADDRESS OF BUSINESS

BUSINESS EIN NUMBER

EDUCATION

HIGH SCHOOL

YES

COLLEGE, TECHNICAL SCHOOL, OR TRADE SCHOOL. IF APPLICANT HAS ATTENDED ANY EDUCATION BEYOND HIGH SCHOOL, LIST IN DETAIL AND GIVE DATES

EMPLOYMENT HISTORY

EMPLOYER #1

E-MAIL

PHONE

ADDRESS

CITY

STATE

ZIP CODE

STARTING PAY $

HOUR

SALARY

ENDING PAY $

HOUR

SALARY

JOB TITLE

RESPONSIBILITIES

STARTING DATE

ENDING DATE

REASON FOR LEAVING

EMPLOYER #2

E-MAIL

PHONE

ADDRESS

CITY

STATE

ZIP CODE

STARTING PAY $

HOUR

SALARY

ENDING PAY $

HOUR

SALARY

JOB TITLE

RESPONSIBILITIES

STARTING DATE

ENDING DATE

REASON FOR LEAVING

EMPLOYER #3

REFERENCES

REFERENCE #1, ADD NAME, RELATIONSHIP, COMPANY, TITLE, EMAIL AND PHONE

REFERENCE #2, ADD NAME, RELATIONSHIP, COMPANY, TITLE, EMAIL AND PHONE

REFERENCE #3, ADD NAME, RELATIONSHIP, COMPANY, TITLE, EMAIL AND PHONE

MILITARY SERVICE

ARE YOU A VETERAN?

YES

BRANCH

YEARS SERVED

HIGHEST RANK ACHIEVED

PLEASE DESCRIBE ANY CURRENT OR PREVIOUS BUSINESS RELATIONSHIPS WITH INDIAN TRIBES, INCLUDING OWNERSHIP INTERESTS IN THOSE BUSINESSES

LIST ANY LICENSING OR REGULATORY AGENCY WITH WHICH THE APPLICANT HAS FILED AN APPLICATION FOR A LICENSE OR PERMIT RELATED TO GAMING, WHETHER OR NOT SUCH LICENSE OR PERMIT WAS GRANTED

CIVIL LITIGATION

IF APPLICABLE, HAS THE APPLICANT EVER BEEN INVOLVED IN ANY CIVIL LITIGATION? IF YES, PLEASE DESCRIBE:

POLICE RECORD

For this section, each question is asking the applicant to respond if any of the following has EVER occurred regardless of whether you believe the record in your case has been sealed, expunged, or otherwise stricken from the court record or the charge was dismissed.

You need not report convictions under the Federal Controlled Substances Act for which the court issued an expungement order under the authority of 21 U.S.C. 844 or 18 U.S.C. 3607. Be sure to include all incidents whether occurring in the U.S. or abroad.

Have you EVER been arrested by a police officer, sheriff, US Marshal, or any other type of law enforcement official including Tribal law enforcement officials?

YES

Are you currently or ever been on probation or parole?

YES

Are you currently on trial or awaiting a trial on criminal charges?

YES

Have you EVER been arrested for or charged with a crime involving a child or offenses committed against children?

YES

Have you EVER been found guilty of, or entered a plea of no contest or guilty to, any offenses under Tribal, Federal, or state law involving crimes of violence, crimes against property, or threats of physical violence to a person or persons?

YES

Have you EVER been found guilty of, or entered a plea of nolo contendere(no contest) or guilty to any offenses under Tribal,Federal or state law involving crimes of sexual assault, molestation, exploitation, contact or prostitution or any other sex crime?

YES

If you have responded “Yes” to any of the above questions in this section, explain your answer(s) below, in detail:

PLEASE PROVIDE THE FOLLOWING - A description of all criminal proceedings in which the applicant was or is currently involved, including all questions answered yes listed above, and the following:

1. For each felony for which there is an ongoing prosecution or a conviction, the charge, the name and address of the court involved, and the date and disposition thereof.

2. For each misdemeanor conviction or ongoing misdemeanor prosecution (excluding minor traffic violations) the name and address of the court involved and the date and disposition thereof; and

3. For each criminal charge (excluding minor traffic charges), whether or not there is a conviction and is not otherwise listed pursuant to the provisions of Subsection (1) and (2) above, the criminal charge, the name and address of the court involved and the date and

disposition thereof.

Illegal Use of Drugs and Drug Activity

DISCOSURE: ALL APPLICANTS SHALL BE SUBJECT TO INITIAL PRE-LICENSING DRUG SCREENING, AS WELL AS RANDOM DRUG SCREENS AT THE YDS GAMING COMMISSION’S DISCRETION THROUGHOUT THE DURATION OF EMPLOYMENT.

BACKGROUNDING AND FINGERPRINTING

ALL APPLICANTS SHALL BE FINGERPRINTED BY

THE YDS GAMING COMMISSION AT TIME OF APPLICATION

BEFORE ISSUING A LICENCE, THE REGULATORY COMMISSION SHALL CREATE AND MAINTAIN AN INVESTIGATIVE REPORT ON EACH BACKGROUND INVESTIGATION. THE INVESTIGATIVE REPORT SHALL INCLUDE THE FOLLOWING:

1. STEPS TAKEN IN CONDUCTING A BACKGROUND INVESTIGATION.

2. RESULTS OBTAINED FROM THE BACKGROUND INFORMATION.

3. CONCLUSION REACHED; AND THE BASIS FOR THE CONCLUSION MADE.

DO YOU CONSENT TO FINGERPRINTING AND BACKGROUND INVESTIGATION?

YES

THE YSD GAMING COMMISSION SHALL RETAIN THE RIGHT TO CONDUCT SUCH ADDITIONAL BACKGROUND INVESTIGATIONS OF ANY PRIMARY MANAGEMENT OFFICIAL, KEY EMPLOYEES, OR OTHER GAMING EMPLOYEES AT ANY TIME DURING THE TERM OF THAT PERSON’S EMPLOYMENT.

DISCLAIMER

I hereby certify that my answers are true and honest to the best of my knowledge. I understand that any false or misleading information in my application or interview may result in denial or revocation of a gaming license.

BY SIGNING THIS APPLICATION, THE APPLICANT IS GIVING FULL CONSENT TO THE YSLETA DEL SUR PUEBLO GAMING COMMISSION TO FINGERPRINT AND CONDUCT A BACKGROUND. ANY INFORMATION NOT DISCLOSED SHALL RESULT IN THE POSSIBILE DENIAL OR REVOCATION OF A GAMING LICENSE.

PRINT NAME

DATE

Additional lines if necesary

Signature