Form Dr 9596 - Gaming License Renewal Application Form

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DR 9596 (Rev. 3/05)

Colorado Limited Gaming Control Commission

COLORADO DEPARTMENT OF REVENUE

GAMING LICENSE

DIVISION OF GAMING

17301 W COLFAX AVE STE 135

GOLDEN CO 80401

RENEWAL APPLICATION FORM

(303) 205-1355

PLEASE VERIFY & UPDATE ALL INFORMATION BELOW

License Application Processing Hours: 9 a.m. to 3 p.m.

Name

Social Security Number

Date of Birth

License Number

License Type

Expiration Date

Due Date

Amount Due

Street Address

Home Phone Number

Sex

Race

City

State

Zip

Length at This Address

Mailing Address

Name of Present Employer

Work Phone

Job Title

1. In the past 2 years, have you been arrested, served with a criminal summons, charged with, or convicted of ANY crime or offense in any manner?

You must include ALL arrests, charges, and convictions regardless of the outcome, even if the charges were

dismissed or you were found not guilty.

You must include ALL arrests, charges, and convictions regardless of the class of crime (felonies, misdemeanors,

and/or petty offenses).

You must include ALL serious traffic offenses, including DUI; DWAI; reckless driving; leaving an accident scene (hit

and run); driving under denial, suspension or revocation; or any other offense resulting in custody.

YES*

*If you answered YES, explain in detail on a separate sheet and attach it to your application. For each offense for which you

were arrested or charged, YOU MUST OBTAIN OFFICIAL DOCUMENTATION FROM THE COURT WHERE YOU

APPEARED, SHOWING THE FINAL DISPOSITION (OUTCOME) OF YOUR CASE.

2. In the past 2 years, have you (A) been delinquent in the filing of (1) any tax return with any taxing agency anywhere; (2) payment of

any taxes, interest, or penalties due any taxing agency anywhere; (3) payment of any obligations to any government agency

anywhere; (4) repayment of any government-issued student loans; and/or (5) payment of any child support; or (B) been denied a gaming

license, withdrawn a gaming license or had any disciplinary action taken against a gaming license in this or any other jurisdiction?

YES*

*If you answered YES, explain in detail on a separate sheet and attach it to your application.

AFFIRMATION & CONSENT

I state under penalty of perjury that the above statements and information are true and correct to the best of my knowledge and belief, and that this

statement is executed with the knowledge that misrepresentation or failure to reveal information requested may be deemed sufficient cause for the

refusal to issue a gaming license by the State of Colorado. Further, I am aware that later discovery of an omission or misrepresentation made in the

above statements may be grounds for the denial of my renewal application or the revocation of my license. I am voluntarily submitting this

application to the Colorado Limited Gaming Control Commission under oath with full knowledge that I may be charged with perjury or other crimes

for intentional omissions and misrepresentations pursuant to Colorado law. I further consent to any background investigation necessary to

determine my present and continuing suitability and that this consent continues as long as I hold a Colorado Gaming License, and for 90 days

following the expiration or surrender of such gaming license. I also agree that the State of Colorado, its agencies, officers and assigns, shall be

entitled to collect from me all expenses incurred in recovery of any debt created by this license application, or in pursuing any other remedy provided

by law, including but not limited to reasonable attorney fees and costs. Note: If your check is rejected due to insufficient or uncollected funds, the

Department of Revenue may collect the payment amount directly from your banking account electronically.

Signature of Applicant

Date

If submitting by mail and paying by credit card, provide Cardholder Name, Card Type, Card Number and Expiration Date below. (Visa and MasterCard only)