S/M Gaming License Application

STOCKBRIDGE-MUNSEE COMMUNITY BAND OF MOHICAN INDIANS

OFFICE OF GAMING COMMISSION

1. APPLICANT NAME: ______

MAILING ADDRESS: ______

______

2. ADDRESS OF GAMING FACILITY WHERE APPLICANT WILL WORK:

Mohican North Star Gaming & Resort W12180A County Road A Bowler, Wisconsin 54416

3. POSITION FOR WHICH LICENSE IS SOUGHT:

PARTY TO MANAGEMENT CONTRACT

PRIMARY MANAGEMENT OFFICIAL

KEY EMPLOYEE (TITLE) ______

OTHER (PLEASE SPECIFY) ______

4. DO YOU HAVE ANY KIND OF CONTRACT OR AGREEMENT, VERBAL OR WRITTEN, WITH THE STOCKBRIDGE-MUNSEE TRIBE, GAMING FACILITY, OR WITH A PARTY TO MANAGEMENT WITH THE TRIBE?

YES (If yes, please explain)

PRIVACY NOTICE

INITIALS:______(1) MGC-FORM 1 (3-26-15) S/M GAMING LICENSE APPLICATION

PERSONAL HISTORY RECORD

Mohican Gaming Commission Compliance Department P.O. Box 70 P.O. Box 70 Bowler, WI 54416 Bowler, WI 54416 (715) 787-2533 (715) 787-2533 (715) 787-3110 (715) 787-3110

*Any corrections or supplemental disclosure information may be directed to an authorized commissioner at the above address.

A. PERSONAL INFORMATION

1. Full Name:

A. ______LAST FIRST FULL MIDDLE

B. Maiden Name: ______

C. List any nickname, alias or other name you have used, including previous married names:

______

2. Current Address: How Long? ______

______Physical/Street Address City/State/Zip

3. Telephone Numbers: Home: (_____) ______Cell: (_____) ______

4. Social Security Number: ______Birth Date: ______-______-______*Refer to Privacy Act Notice on Page #1

Place of Birth: ______City County State

Country (if other than United States: ______

5. Drivers License Number: ______Issuing State: ______

If different from the above, list the Drivers License Number and Issuing State for every driver’s license you have had over the past five (5) years:

______

6. Physical Description:

A) Eye Color: ______D) Weight: ______

B) Hair Color: ______E) Height: ______

C) Race: ______F) Gender: Male Female

7. Are you a citizen of the United States? YES ______NO ______

If no, then of what country are you a citizen? ______2 S/M GAMING LICENSE APPLICATION

8. If an Alien:

Registration Number: ______

9. If Naturalized:

Certificate Number: ______Date: ______-______-______

Place of Naturalization: ______City County State

10. List all Languages spoken or written:

______

B. PHOTOGRAPH DATE OF PHOTOGRAPH: ______-______-______

C. MARITAL INFORMATION

1. Status: A) Single: _____ B) Married: _____

2. Current Marriage:

A) Date: ______-______-______B) Location: ______City State

C) Spouse’s Full Name: ______Last(Maiden Middle First

D) Date of Birth:______-______-______

E) Residence Address: ______Street Address City/State/Zip

F) Telephone Number: Home: (_____) ______Work: (_____) ______

G) Spouse’s Occupation: ______

H) Spouse’s Employer: ______

3. Previous Marriages: If ever legally separated, divorced, or annulled, indicate below:

Name of Spouse Date Nature of Action City, County State

INITIALS: ______(3) MGC-FORM 1 (3-26-15) S/M GAMING LICENSE APPLICATION

D. ARRESTS, CONVICTIONS, OR PARTY TO A CIVIL ACTION

1. Have you ever been arrested, detained, charged, indicted, or summoned to answer for any FELONY, regardless of the disposition of the event?

A) YES ______If YES, provide the following information for each offense:

1) Date of plea or conviction

2) State and Jurisdiction in which plea or conviction occurred, name of the Court

3) The specific charge or offense, including a statutory or ordinance citation

4) Attach a certified copy of the complaint and disposition

B) NO ______

2. Have you ever been arrested, detained, charged, indicted, or summoned to answer for any MISDEMEANOR, regardless of the disposition of the event?

A) YES ______If YES, provide the following information for each offense:

1) Date of plea or conviction

2) State and Jurisdiction in which plea or conviction occurred, name of the Court

3) The specific charge or offense, including a statutory or ordinance citation

4) Attach a certified copy of the complaint and disposition

B) NO ______

3. Have you ever been arrested, detained, charged, indicted, or summoned to answer for any ORDINANCE VIOLATION, regardless of the disposition of the event?

A) YES ______If YES, provide the following information for each offense:

1) Date of plea or conviction

2) State and Jurisdiction in which plea or conviction occurred, name of the Court

3) The specific charge or offense, including a statutory or ordinance citation

4) Attach a certified copy of the complaint and disposition

B) NO ______

4. Have you ever been arrested, detained, charged, indicted, or summoned to answer for any GAMBLING-RELATED OFFENSE, FRAUD, or MISREPRESENTATION in any connection for any reason whatsoever, regardless of the disposition of the event? 4 S/M GAMING LICENSE APPLICATION A) YES ______If YES, provide the following information for each offense: 1) Date of plea or conviction

2) State and Jurisdiction in which plea or conviction occurred, name of the Court

3) The specific charge or offense, including a statutory or ordinance citation 4) Attach a certified copy of the complaint and disposition B) NO ______

5. Have you ever been charged for any CRIME (excluding minor traffic violations), regardless of the disposition of the event? A) YES ______If YES, provide the following information for each offense: 1) Date of plea or conviction

2) State and Jurisdiction in which plea or conviction occurred, name of the Court

3) The specific charge or offense, including a statutory or ordinance citation 4) Attach a certified copy of the complaint and disposition B) NO ______

6. Were you ever an employee, director, owner or partner of a business that was convicted or pled no contest to a FELONY, GAMBLING-RELATED OFFENSE, FRAUD, or MISREPRESENTATION in any connection? A) YES ______If YES, provide the following information for each offense: 1) Name, address, and telephone number of the corporation association, partnership or trust 2) Date of plea or conviction

3) State and Jurisdiction in which plea or conviction occurred, name of the Court

4) Attach a certified copy of the complaint and disposition

B) NO ______

E. RESIDENCES

1. List all residences you have had for the last 5 years, beginning with the most recent first. If additional room is needed attach an additional sheet:

Month & Year (From – To) Street & Number City State and County

INITIALS: ______(5) MGC-FORM 1 (3-26-15) S/M GAMING LICENSE APPLICATION F. MILITARY INFORMATION

1. Have you ever served in the Armed Forces? YES ______NO ______

If YES, please provide copy of your DD-214 and if you were in the National Guard/Reserves please provide a copy of an NGB-22

G. EMPLOYMENT

1. Beginning with your most recent employment, list your work history, all businesses with which you have been involved, and/or all periods of unemployment in the last five years. Provide the following information for each: (Use an additional sheet if more space is needed)

Month &Year Name/Mailing Address of Employer/Business Ownership interest? Reason for leaving Be specific (From–To) YES NO

Title Phone # Gaming present? YES NO

Description of Duties Name of Supervisor

Month &Year Name/Mailing Address of Employer/Business Ownership interest? Reason for leaving Be specific (From–To) YES NO

Title Phone # Gaming present? YES NO

Description of Duties Name of Supervisor

Month &Year Name/Mailing Address of Employer/Business Ownership interest? Reason for leaving Be specific (From–To) YES NO

Title Phone # Gaming present? YES NO

Description of Duties Name of Supervisor

Month &Year Name/Mailing Address of Employer/Business Ownership interest? Reason for leaving Be specific (From–To) YES NO

Title Phone # Gaming present? YES NO

Description of Duties Name of Supervisor

H. BUSINESS INFORMATION

6 S/M GAMING LICENSE APPLICATION

1. Attach a list of all businesses: sole proprietorships, corporations, associations, partnerships, or trusts, whether gaming-related or not, both within and outside the State, in which you are an officer, director, investor or owner directly or indirectly.

A) YES ______If YES, provide the following information for each on a separate sheet:

Name of entity, Address, telephone number and your relationship to the entity

B) NO ______

2. Have you ever been associated as an officer, director, stockholder, partner or sole proprietor with any business entity that has filed for protection under the Federal Bankruptcy Law?

YES NO

3. Do you have an existing or had a previous business relationship or an ownership interest in any business with any Indian Tribes or Indian Gaming?

A) YES ______If YES, please describe

B) NO ______

I. FINANCIAL INFORMATION

1. Year of last Federal Income Tax Return filed: ______

J. LICENSES

1. Have you ever filed for an occupational or professional license in any state, including but not limited to the following: A) Liquor/Bartender F) Boxing Promoter

B) Real Estate Broker/Salesman G) Race Horse/Race Dog Owner

C) Accountant H) Jockey

D) Lawyer I) Trainer or Manager

E) Doctor J) Securities Dealer

A) YES ______If yes, on a separate sheet please provide the following information for each license held:

1) Name and address of the licensing or regulatory agency with which you filed

2) Type of license and whether a license was granted

3) State where license was held and years license was held

4) Nature of any disciplinary action taken against you INITIALS: ______(7) MGC-FORM 1 (3-26-15) S/M GAMING LICENSE APPLICATION 5) provide a certified copy of each license

B) NO ______

2. Have you ever filed an application for a license, permit or certificate related to gaming?

A) YES ______If yes, provide the following information for each license held:

1) Name and address of the licensing or regulatory agency with which you filed

______

2) Whether an application or license was denied, withdrawn, suspended, disciplined,

sanctioned, special conditions invoked or otherwise noticed or admonished?

Yes ______Please explain ______

No ______

B) NO ______

K. CHARACTER REFERENCES

List four character references with at least one who was acquainted with you during each period of residence in the last five years. Please do not include relatives, cohabitants, Stockbridge-Munsee Tribal Council, Mohican Gaming Commission and Compliance Department.

1) Name: ______Address: ______Length of time you have known this person: ______Employer: ______Telephone Numbers: Home: (______) ______Work: (______) ______Cell: (______) ______

2) Name: ______Address: ______Length of time you have known this person: ______Employer: ______Telephone Numbers: Home: (______) ______Work: (______) ______Cell: (______) ______

3) Name: ______Address: ______8 S/M GAMING LICENSE APPLICATION Length of time you have known this person: ______Employer: ______Telephone Numbers: Home: (______) ______Work: (______) ______Cell: (______) ______

4) Name: ______Address: ______Length of time you have known this person: ______Employer: ______Telephone Numbers: Home: (______) ______Work: (______) ______Cell: (______) ______

THE APPLICANT AGREES TO THE FOLLOWING:

(A) TO COMPLETE, SIGN, NOTARIZE, AND ATTACH: PERSONAL HISTORY FORM, FINANCIAL QUESTIONAIRE, AND FINGERPRINT CARDS THAT BECOME PART OF THE APPLICATION.

(B) TO COMPLETE, SIGN NOTARIZE, AND ENCLOSE WITH THE APPLICATION THE FOLLOWING FORMS: AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION AND RELEASE OF ALL CLAIMS.

(C) IN ADDITION TO THE CRIMINAL HISTORY INFORMATION REQUIRED TO BE SUBMITTED IN CONNECTION WITH ANY BACKGROUND INVESTIGATION OR WITH THE LICENSE APPLICATION, TO REPORT ANY ONGOING FELONY OR MISDEMEANOR PROSECUTIONS OR CONVICTIONS (OTHER THAN MINOR TRAFFIC VIOLATIONS), INCLUDING BUT NOT LIMITED TO ONGOING PROSECUTIONS OR CONVICTIONS FOR FRAUD OR MISREPRESENTATION OR ANY GAMING-RELATED OFFENSE, ARISING AT ANY TIME DURING THE PENDENCY OF THE LICENSE APPLICATION OR DURING THE LICENSING PERIOD.

(D) TO PROVIDE SUCH FINANCIAL DATA OR OTHER INFORMATION NOT REQUIRED TO BE SUBMITTED HEREWITH THAT MAY BE DEEMED NECESSARY OR APPROPRIATE BY THE MOHICAN GAMING COMMISSION TO PROVIDE FURTHER DETAIL AS TO FITNESS FOR LICENSE OR TO VERIFY INFORMATION OTHERWISE REQUIRED BY THIS LICENSE.

(E) TO NOTIFY THE MOHICAN GAMING COMMISSION WITHIN FIFTEEN (15) DAYS OF THE OCCURRENCE OF ANY CHANGE IN THE INFORMATION PROVIDED IN CONNECTION WITH THIS APPLICATION.

I, ______, BEING DULY SWORN, DEPOSE AND SAY THAT THE STATEMENTS IN THIS APPLICATION 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, REVOCATION, OR SUSPENSION OF A GAMING LICENSE BY THE TRIBAL COUNCIL OR GAMING COMMISSION; FURTHER, I AM AWARE THAT LATER DISCOVERY OF AN OMISSION OR MISREPRESENTATION MADE IN THE ABOVE STATEMENTS MAY BE GROUNDS FOR THE REVOCATION OF A GAMING LICENSE; FURTHER, THAT I AM VOLUNTARILY SUBMITTING THIS APPLICATION UNDER OATH TO THE MOHICAN GAMING COMMISSION CHARGED BY THE LAW WITH GRANTING GAMING LICENSES.

INITIALS: ______(9) MGC-FORM 1 (3-26-15) S/M GAMING LICENSE APPLICATION ______APPLICANT’S SIGNATURE DATE

State of Wisconsin

County of Shawano

SUBSCRIBED AND SWORN TO BEFORE ME THE ______DAY OF

______, 20______

______Notary Public

MY COMMISSION EXPIRES: ______-______-______

NOTICE THIS APPLICATION MAY NOT BE WITHDRAWN WITHOUT THE PERMISSION OF THE GAMING COMMISSION

10 S/M GAMING LICENSE APPLICATION

STOCKBRIDGE-MUNSEE COMMUNITY BAND OF MOHICAN INDIANS

OFFICE OF GAMING COMMISSION

AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION INDIVIDUAL LICENSE APPLICANT (Page 1 of 2)

(FOR OFFICE USE ONLY)

1. I, ______do hereby authorize all persons and entities to whom this request is presented, having information relating to or concerning me, and/or having written documents or records relating to me or concerning me, to furnish any such information to the Mohican Gaming Commission (“Commission”) or the Stockbridge-Munsee Compliance Department (“Compliance”), the duly appointed agent of the Stockbridge-Munsee Community, whether or not such information would otherwise be protected from disclosure by any constitutional, statutory or common law privilege, except for information protected from disclosure under attorney/client privilege or the work product doctrine. Such information is required as part of a background investigation to obtain a Tribal gaming license.

2. I hereby authorize specifically that the following persons and entities furnish the Commission and/or Compliance, upon request, with any and all documents and information they have pertaining to me:

(a) Any branch of the Armed Forces, including but not limited to the Army, Navy, Marines, Air Force and the Coast Guard or any reserve unit of these branches, is authorized to release and furnish all military records including evaluation reports, court martial’s, any course records and any other documents in their possession. (b) Any educational facilities, including but not limited to grade schools, junior and senior high schools, technical schools, colleges or universities, or army extension or program of the afore-mentioned facilities, are authorized to release and furnish copies of attendance and behavior records, transcripts, correspondences, disciplinary actions, awards, certificates, degrees, grade point average and class standing and any other documents and information in their possession. (c) Any business establishment and/or employer are authorized to release and furnish copies of employment applications, resumes, promotions and demotions, letters of reprimand and appreciation, performance evaluations, resignation or dismissal records, disciplinary and any other letters and information in their possession. (d) Any and all state and federal law enforcement agencies are authorized to release and furnish copies of arrest, incarceration and warrant records, field reports, computer entries and any other documents or information in their possession. (e) Any private, state, or federal agency responsible for regulating the following fields including but not limited to medical, legal, securities, accounting, liquor, gaming, real estate, teaching, insurance, private investigating, and/or security, is authorized to release and furnish copies of the applications, tests, and results, official and unofficial records, any complaints, reprimands, board meeting notes, investigations and background information, and any other documents or information in their possession. (f) Any financial institution, including but not limited to any credit reporting company, bank, credit union, collection agency, company, or loan company is/are authorized to release and furnish copies of any financial information, records, reports loan agreements, statements and any other documents or information in their possession.

3. I do, for myself, my heirs, executors, administrators, successors, and assigns, hereby release, surrender and forever discharge any person to whom this request is presented and his agents and employees from any and all manner of actions, causes of action, suits, debts, judgments, executions, claims, and demand whatsoever, known or unknown, in law or equity, which I ever had, now have, or may have, or may claim to have against such person or his agents or employees arising out of or by reason of complying with this request. INITIALS: ______(11) MGC-FORM 1 (3-26-15) S/M GAMING LICENSE APPLICATION

4. I agree to indemnify and hold harmless any person to whom this request is presented and his/her agents and employees from and against all claims, damages, loses, and expenses, including reasonable attorney’s fees, arising out of or by reason of complying with this request.

5. A reproduction of this request by photocopy or similar process shall be for all intents and purposes as valid as the original.

APPLICANT NAME: ______

DATE OF BIRTH: ______-______-______

SOCIAL SECURITY #: ______-______-______*Please refer to Privacy Act Notice

In witness whereof, I have executed this Authorization for Release of Personal Information – Individual License Applicant at

Bowler, Wisconsin, on the ______day of ______, 20______

______APPLICANT SIGNATURE

State of Wisconsin

County of Shawano

Subscribed and sworn to before me the ______day of ______, 20______

______Notary Public

My commission expires: ______-______-______

Signature of Tribal Council Agent presenting this request:

______

INITIALS: ______(12) MGC-FORM 1 (3-26-15) S/M GAMING LICENSE APPLICATION

STOCKBRIDGE-MUNSEE COMMUNITY BAND OF MOHICAN INDIANS

OFFICE OF GAMING COMMISSION

RELEASE OF ALL CLAIMS - INDIVIDUAL

The undersigned individual, ______(the “Applicant”) has filed or will file with the Mohican Gaming Commission (“Commission”) an application for a gaming license. In consideration of the assurance by the Commission that no vote on said application will be taken except after a deliberate, intensive and thorough investigation of the Application, including but not limited to background, associates, and finances, the Applicant does hereby, to the extent of compliance with the foregoing by the Commission, for the Applicant and the Applicant’s successors and assigns, release, remise and forever discharge the Stockbridge-Munsee Community and their respective members, agents, and employees, from any and all manner of actions, causes of action, suits, debts, judgments, executions, claims and demands whatsoever, known or unknown, in law or equity, which the Applicant ever had, now has, may have, or may claim to have against any or all of said entities or individuals arising out of or by reason of the processing or investigation or other action relating to the Applicant’s application.

I, ______, have read this release and understand all of its terms. I execute it voluntarily and with full knowledge of its significance.

______Applicant Signature Date

State of Wisconsin

County of Shawano

Subscribed and sworn before me the _____ day of ______, 20_____

______Notary Public

My Commission expires: ______-______-______

Copyright  2015 The Stockbridge-Munsee Community (SMC) All Rights Reserved No parts of this form may be reproduced, stored, or transmitted by any means without prior INITIALS: ______(13) MGC-FORM 1 (3-26-15) S/M GAMING LICENSE APPLICATION written permission of SMC

INITIALS: ______(14) MGC-FORM 1 (3-26-15)