Sponsored Gaming Employee License Application |
Maryland State Lottery Commission |
MARYLAND STATE LOTTERY COMMISSION
VIDEO LOTTERY GAMING EMPLOYEE LICENSE APPLICATION
I.INDIVIDUALS REQUIRED TO OBTAIN A VIDEO LOTTERY GAMING EMPLOYEE LICENSE:
a.This application must be completed by an individual who has received at least a conditional offer of employment from a licensed facility operator, manufacturer or contractor as a video lottery employee, and whose duties relate or will relate to the operation of a facility, and who performs or supervises or will perform or supervise the performance of: (1) operating, servicing, or maintaining a video lottery terminal or associated equipment; (2) accounting, maintaining, or auditing a facility’s financial records; (3) counting or processing video lottery terminal revenue; (4) conducting security or surveillance in or around a facility; (5) operating or maintaining a facility’s information systems; (6) is employed by a contractor or manufacturer, whose duties directly relate to the repair, service or distribution of a video lottery terminal and associated equipment, or is otherwise required to be present on a facility’s gaming floor or in a restricted area of a facility; or (7) is otherwise required by the Commission to be licensed as a gaming employee. Examples of gaming employees may include, but are not limited to: booth operators, slot machine mechanics, count room employee, cage employee, security and surveillance personnel, auditing and accounting employees, or information technology employees.
b.An individual who is employed by licensee described above whose duties will be other than the duties described in (a) above are not required to obtain a gaming employee license. Those individuals are required to obtain a non-gaming license.
II.COMPLETING THIS FORM:
Sponsoring Licensee’s Responsibilities
a.This form is to be used only when a holder of a Maryland Video Lottery Manufacturer, Operator or Contractor Gaming License (sponsored licensee) makes application for an employee applicant who has been offered a position within the sponsored licensee business.
b.The form will be filled out by the applicant employee not the sponsored licensee. The sponsored licensee is responsible for completing the Certification of Sponsored Licensee at the end of this application.
c.The form must be submitted to the Commission by the Sponsored Licensee not the applicant employee.
Applicant Employee’s Responsibilities
d.You are to complete this form and submit it to the sponsored licensee for submission to the Commission.
e.You must make accurate statements and include all material facts. Any misrepresentation, or the failure to provide requested information, may result in the denial of your application.
f.Read each question carefully prior to answering. Answer every question completely. Do not leave blank spaces. If a question does not apply to you or you have nothing to disclose, indicate “Does Not Apply” in response to that question. Failure to provide a response to every question could result in the denial of your application.
g.If the space available is insufficient to respond to a question, supply the required information on an attachment page and clearly identify which question you are answering.
h.If you make any modification to the pre-printed questions or information contained in this form, your application may be denied. Once your application is submitted, it becomes the property of the Maryland State Lottery Agency and will not be returned.
III. BE SURE:
a.You sign the Statement and Authorization at the end of this form in the presence of a notary.
b.You retain a completed copy of your application for your own records.
IV. PHOTOGRAPH AND FINGERPRINTS
VLT Form 2003 (Rev July 21,2011) |
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Sponsored Gaming Employee License Application |
Maryland State Lottery Commission |
a.You will be required to have your photograph taken when your application is made.
b.You will be required to submit fingerprints upon application.
V.NOTICES
a.A Maryland gaming license is a privilege. The burden of proving and maintaining qualifications to receive and hold a gaming employee license is at all times on the applicant.
b.Any false statement made in this application will reflect on your character and may result in the denial of your application or, if you receive a license based on a false statement, may result in suspension or revocation of your license.
c.When the Commission completes its background investigation and you are found qualified for a Maryland license this license will automatically convert to a video lottery employee gaming license. Should you not be found qualified your sponsored gaming employee license will become the subject of revocation and suspension proceedings before the Commission.
NOTE: AN APPLICATION THAT HAS BEEN ACCEPTED FOR FILING AND ALL RELATED MATERIALS SUBMITTED TO THE COMMISSION SHALL BECOME THE PROPERTY OF THE COMMISSION AND WILL NOT BE RETURNED TO THE APPLICANT.
APPLICATION AND REGISTRATION FEES
1. |
Application fee |
$ 250.00 |
2. |
Finger print processing fee |
$ 37.25 |
3. |
License fee |
$ 150.00 |
4. |
Initial term |
3 Year |
5. |
Renewal fee |
$150.00 |
6. |
Renewal term |
3 Year |
Note: License, Application & Fingerprint fees are due at the time of application. They are
non-refundable. You may wire transfer your payment or mail it to the following address:
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DO NOT MAIL APPLICATION AND PAYMENT TOGETHER!!! |
Mail payment to: |
Maryland State Lottery Agency |
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Attn: Support Services |
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1800 Washington Blvd, Suite 330 |
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Baltimore, Maryland 21230 |
Mail the application to the same address, except: Attn: VLT Licensing Division.
PAYMENT FORM: MUST be sent as a certified/bank check or money order.
VLT Form 2003 (Rev July 21,2011) |
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Sponsored Gaming Employee License Application |
Maryland State Lottery Commission |
Name of Gaming Licensee:
(You must have an offer to work from a Licensee :)
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Type of Licensee |
Operator |
Manufacturer |
Contractor |
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Position Applicant is Applying for: |
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1. |
Last Name |
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NAME AND ADDRESS |
Suffix(Jr.. Sr., etc.) |
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First Name |
Middle Name |
2. |
Maiden Name |
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3. |
Date of Birth |
4. |
Address Line 1 |
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Address Line 2 |
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P. O. Box |
City |
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County |
State/Province |
Zip Code |
Country |
5. Email Address |
6. Home Phone |
7. Cell Phone |
MAILING ADDRESS (If different from above)
8. Address Line 1 |
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Address Line 2 |
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P. O. Box |
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City |
County |
State/Province |
Zip Code |
Country |
Email Address |
Home Phone |
Cell |
DESCRIPTIVE INFORMATION
9. |
Height |
10. Weight |
11. |
Social Security Number |
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12. Driver’s License |
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FT |
IN |
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lbs |
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State Issued: |
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13. |
Do you have any tattoos, scars or distinguishing marks? |
If yes, |
14. |
» IARITAL STATUS: |
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describe in detail: |
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SINGLE |
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MARRIED |
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15. |
PLACE OF BIRTH: |
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SEPARATED |
DIVORCED |
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City/Town |
State/Province |
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Country |
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WIDOWED |
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DOMESTIC PARTNER |
16. |
Name of Spouse |
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17. |
Spouse’s Maiden Name or |
18. spouse |
19. |
Spouse’s Social Security' Number |
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AKA |
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DOB |
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20. |
HAIR COLOR |
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21. |
EYE COLOR |
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22. |
SEX |
23. |
RACE* |
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Are y ou of Hispanic/Latino origin? |
Yes |
No |
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(BK)Black |
(BR) Brown |
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(BK) Black |
(BR) Brown |
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(M) Male |
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Caucasian |
Black/African American |
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(BD) Blonde |
(RD) Red |
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(HZ) Hazel |
(BL) Blue |
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(F) Female |
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Native Hawaiian/Pacific Islander |
Asian |
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(GY) Gray |
(WH) White |
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(GY) Gray |
(GR) Green |
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American Indian/Alaska Native О Other: |
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(BA) Bald |
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♦ Multiracial respondents may select all applicable racial |
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categories. |
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LIST ANY OTHER NAME OR NAMES YOU HAVE BEEN KNOWN BY (INCLUDE ALIASES. NICKNAMES. MARRIED NAMES)
24.Have you been known by any other name or names? О YES О NO If YES, list the additional names below and specify dates for use for each. Include maiden name, aliases, nicknames or any other names used.
LAST NAME |
FIRST NAME |
MIDDLE NAME |
SUFFIX |
FROM |
TO |
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DATE |
DATE |
VLT Form 2003 (Rev July 21, 2011) |
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Sponsored Gaming Employee License Application |
Maryland State Lottery Commission |
25. |
Are you a United States citizen? |
YES |
NO |
If NO, complete the following: |
a. |
Country of Citizenship: |
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Name and Address of sponsor |
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upon your arrival: |
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b. |
If a naturalized citizen complete: |
1. |
C.I.S. Registration Number: |
2.Date Granted:
3.Court:
4.City/State of Court:
5.Certificate Number:
c. If you are a legally authorized Permanent Resident Alien, provide the “A" number from your Permanent Resident Card:
Card Number: |
(Attach a color copy front and back) |
d.If you do not posses a Permanent Resident Card but are authorized to work in the United States, please describe the U. S. Work Visa that you possess and provide the Visa number:
Description of Authorization:
VISA #:
26. Have you ever been issued a passport? |
YES |
NO |
If, yes please complete the following: |
Passport Number |
Country of Issue |
Place Issued |
Date Issued |
Expiration Date |
DEPENDENTS
27.In the chart below, list the names of all your children, stepchildren and adopted children and the amount of support, if dependent. Also, list all other persons who you are supportin g or contributing to the support of, and provide the amount of support.
Name of Children/Dependent |
Date of Birth |
Amount of |
Present Address of |
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Support |
Children/Dependents |
VLT Form 2003 (Rev July 21,2011) |
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Sponsored Gaming Employee License Application |
Maryland State Lottery Commission |
RESIDENCE
28.Beginning with your current residence(s) and working backwards, complete the following information for each place where you have lived (including residences while attending college or while in the military service) during the past ten (10) years or since the age Of 18, whichever is less. If additional space is needed, attach a separate sheet making
certain to indicate the question number.
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Dates |
Address |
Own |
Name, address & telephone no. of mortgage |
From: |
To: |
(no, street, apt. #, City/town, state/province, zip |
Or |
company or landlord, if any |
(Mo/Yr) |
(Mo/Yr) |
code |
Rent |
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EDUCATION
29.Beginning with your highest level of education and working backwards complete the information listed below with respect to each school, college, graduate or postgraduate school you have attended, if additional space is needed,
attach a separate sheet making certain to indicate the question number.
From: |
Dates |
Name and Address of |
Description of |
List any Degree |
Graduated |
To: |
(Mo/Yr) |
(Mo/Yr) |
School, Training program, etc. |
Educational Program |
or Certification |
Yes/No |
VLT Form 2003 (Rev July 21, 2011) |
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Sponsored Gaming Employee License Application |
Maryland State Lottery Commission |
EMPLOYMENT
30.Beginning with your present job and working backwards, list below all periods of employment for the past ten years or from age 18, whichever is less. Give dates of any unemployment between jobs in proper sequence. Include all part-time and full-time employment and anv military service. For any casino, horse racinq or qaminq related employment, please list your license number under “Title.” (If additional space is needed, attach a separate
sheet making certain to indicate the question number.) Have you been in the Military? |
Yes E)No If yes, list regardless of time. |
Dates |
Name, Address and telephone Number |
Title/Position Held and |
Supervisor’s |
Reason for leaving/ |
From: |
To: |
(Mo/Yr) |
(Mo/Yr |
of Employer(s) |
Description of Duties |
Name |
Compensation at |
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Departure |
31. Have you ever been discharged or asked to resign from a job? |
No |
Yes If Yes, complete below. |
Employer’s Name & Address |
Date of Discharge or |
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Reason for Leaving |
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Resignation |
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VLT Form 2003 (Rev July 21, 2011) |
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Sponsored Gaming Employee License Application |
Maryland State Lottery Commission |
CIVIL, CRIMINAL & INVESTIGATORY PROCEEDINGS
Prior to answering this question, carefully review the definitions and instructions which follow .
DEFINITIONS: For purposes of this question:
A.“Arrest” includes any time that you were stopped by any law enforcement officer and advised that you were under arrest, detained, held for questioning or were requested by a law enforcement officer to come to a law enforcement office or facility and answer questions. “Arrest” also includes any circumstances in which you were taken into custody by any law enforcement officer, fingerprinted, detained in any jail or detention center, or otherwise been the subject of a court order to appear in a judicial proceeding in which you were accused of a “crime or offense” as defined in subsection C.
B.“Charge” includes any indictment, complaint, information, summons, or other notice of the alleged commission of any “offense.”
C.“Offense” includes all felonies, misdemeanors, and summary offenses that may have required you to appear before any municipal, state, or federal grand jury, court, or any other judicial tribunal except juvenile court. “Offense” also includes all driving-related charges or offenses which carry any period of incarceration.
INSTRUCTIONS:
1.Answ er “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 or downgraded to a lesser charge;
C.You completed a pretrial intervention or other rehabilitation or diversionary program;
D.You were not convicted;
E.You did not serve any time in a correctional facility;
F.The charges or offenses happened a long time ago; or
G.You were not arrested for the charge.
2.Answer “NO” if:
a)You have never been charged with or arrested for any crime or offense;
b)Your were arrested or charged when you were under eighteen (18) years of age and your arrest or charge, including any sentence that a court imposed, was adjudicated entirely in juvenile court;
c)The records of the charge or arrest have been expunged pursuant to an order of court or
otherwise sealed by a court of competent jurisdiction.
I I 1 have read and understand the definitions and instructions
IMPORTANT
Maryland tvi/Z make inquiries to establish w hether the identified individuals have had any involvement with law
enforcement agencies.
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Failure to disclose anv such involvement w ill be taken into account in |
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assessing the Applicant’s character, honesty and integrity. Do you understand?: 1 1 |
YES |
NO |
32. Have you ever been arrested or charged w ith any offense in any jurisdiction? |
1 1 YES |
1 1 NO |
If yes, complete the follow ing chart: |
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Disposition |
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Nature of Charge or |
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Name and Address of |
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Date of Charge or |
(Convicted, |
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Law Enforcement |
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Sentence |
Offense/Location of Where |
Acquitted, |
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Offense |
Agency or Court |
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(if any) |
Incident Occurred |
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Dismissed, Pending, |
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Involved |
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Pardoned, etc.) |
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Sponsored Gaming Employee License Application |
Maryland State Lottery Commission |
33.To the best of your knowledge, has a criminal indictment, information or complaint ever been filed or returned against you, or named you as an unindicted party or unindicted co-conspirator in any criminal proceeding in any
If yes, complete the follow ing chart:
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Name and Address of Governmental |
Nature of Proceeding |
Outcome/Disposition |
Date |
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Agency/Organization Involved |
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34.To the best of your knowledge, have you ever been the subject of an investigation conducted by any governmental agency/organization, court, commission, committee, grand jury or investigatory body (local, state, county, provincial, federal, national, etc.) other than in connection with a traffic summons?
YES ONO
Ifyes^complete the following chart:
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Name and Address of Court or |
Nature of Proceeding |
Was |
Date on which |
Approximate Time Period of |
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Testimony |
Testimony |
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Other Agency |
or Investigation |
Investigation |
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Given? |
was Given |
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35. Have you ever received a pardon, or has any government agency/organization dismissed, suspended or deferred any
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criminal investigation or prosecution against you for any criminal offense? |
О YES I I NO |
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If yes, complete the following chart: |
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Date of Pardon, Dismissal, |
Type of Action Taken |
Name and Address of Government Agency/Organization |
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Suspension or Deferral |
Granting Pardon, Dismissal, Suspension or Deferral |
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36.Have you or any business entity with which you are or were associated, ever filed under bankruptcy, been petitioned into bankruptcy or made a proposal under any bankruptcy or insolvency law in any jurisdiction?
No |
Yes |
If yes, complete below: |
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Date Filed |
Docket # |
Name & Address of Court |
Date Judgment |
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Entered. |
VLT Form 2003 (Rev July 21, 2011) |
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