Form Dr 9596 - Gaming License Renewal Application Form Page 7
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7Colorado Division of Gaming
STATEMENT OF UNDERSTANDING
As a gaming licensee, I understand I am responsible for knowing and complying with state laws and regulations
governing limited gaming. I understand I may obtain or view these documents at any of the Division of Gaming
offices. I understand I am being made aware of the following regulations and agree to comply with them:
I am required to notify the Golden office of the Division of Gaming online or in writing of any arrest, criminal charge,
or conviction pending against me within 10 days of such arrest, charge or conviction. This notification requirement
shall not apply to non-felony traffic violations unless they result in suspension or revocation of a driver’s license, are
based on allegations of driving under the influence or impairment of intoxicating liquor or drugs, or result in me being
taken into custody. [Regulation 47.1-405(4)] In addition, infractions which must be reported include reckless driving,
leaving the scene of an accident (hit and run), driving under denial, suspension, or revocation.
I may pay a $5 fee to obtain a duplicate license. (Regulation 47.1-232)
I am required to renew my gaming license 30 days before the expiration of the license I am being issued.
[Regulation 47.1-302(2)] (Note: You should receive a renewal application in the mail60-90 days prior to your
expiration date, but you are still ultimately responsible to obtain a renewal application if you do not receive one in
the mail and to file 30 days before expiration.)
If I allow my Gaming license to expire for even one day and then try to reapply, I must submit an original
license application along with the original application fee. [Regulation 47.1-303(3)]
I understand during the period in which I hold a gaming license, I must:
File state and federal income tax returns;
Remain current on all state and federal tax and other governmental obligations, including any present and/or
future payment plans;
Remain current on all government-insured student loan obligations, including any present and/or future pay-
ment plans;
Remain current on all child support obligations, including any present and/or future payment plans.
I understand the Division of Gaming will perforn1 a background check one year from the month in which my license is
being issued to check whether I have filed necessary tax returns and remained current on the govemment obliga- tions
listed above, and whether I have any outstanding arrest warrants. I understand if the Division of Gaming contacts me
regarding any issues associated with this annual check, I will provide any infonnation the Division of Gaming requests
to show my continued suitability to hold a gaming license.
I understand I am responsible to notify the Division of Gaming office in writing when I have a change in name,
residence address, mailing address or phone number, since all correspondence is sent to my last known address.
Failure to notify the Division could result in my not receiving approval letters, renewal applications, legal notices, and
other correspondence.
I have read all of the above information and understand my responsibilities as a gaming licensee. I further under- stand
that failure to comply with any law, regulation, or the provisions of this Statement may be grounds for disci- plinary
action, including but not limited to the suspension or revocation of my gaming license and a monetary penalty after
an administrative hearing.
LICENSEE'S FULL PRINTED NAME
LICENSE NUMBER
LICENSEE'S SIGNATURE
DATE
white-Division copy
canary-Licensee copy
DR 96328 (Rev. 06/13)
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