Name

Current Address

Contact Information

Are you a member of a federally recognized Tribe or First Nations?

Availability

Personal References

Work Experience
(Starting with your present or last job first)

Education

Continuing Education / Training & Other Experiences

I certify that answers giving herein are true and complete. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. This application for employment shall be considered active for a period of time not to exceed 90 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not application as being accepted at that time. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee ay resign at any time and the Employer may discharge the Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of the organization. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

Additional Information

Please Read: In compliance with the Privacy Act of 1974, the following information is provided: Solicitation of the information on this form is authorized by 25 U.S.C. 2701 et seq. 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 and by the National Indian Gaming Commission (NIGC) members and staff who have need for the information in the performance of their official duties. The information may be disclosed by the Tribe or the NIGC 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 or the NIGC 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's being unable to license you for a primary management official or key employee position. The disclosure of your Social Security Number (SSN) is voluntary. However, failure to supply a SSN may result in errors in processing your application. 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. Also, you may be punished by a fine or imprisonment (U.S. code, title 18, section 1001).

Extra Personal Information

List places of residence for the last five (5) years

List three (3) personal references including one for each addess listed above

List any business you have owned or had an interest in for the past five (5) years

Business relationships current or in the past with Indian Tribes or Gaming Industry:

List previous gaming or occupational permits or licenses applied for

List each Felony for which there is an ongoing prosecution or a conviction

List each Misdemeanor (excluding minor traffic violations) for which there is an ongoing prosecution or a conviction, within the last 10 years

List each Criminal Charge (excluding minor traffic violations) whether or not there is a conviction, if such criminal charge is within the last 10 years and is not otherwise listed above

I, hereby authorize release for the Grand Portage Tribal Council (RTC) any information requested in order for the RTC to determine eligibility for employment or licensing.

This document authorizes release of requested information whether or not such information would otherwise be protected from disclosure by any constitutional, statutory or common law privilege.

I agree to accept any risk of adverse public notice, embarrassment, criticism or financial loss that may result from use of information that is obtained in connection with a background investigation for the purposed listed in the first paragraph of this document.

I authorize release of any information related to my activities including: schools, property interests (real or personnel), employment, criminal justice agencies, regulatory agencies, business, financial institutions, lending institutions, medical institutions, hospitals, and health care professionals.

I authorize review and copying of all documents.

I relinquish any rights that I may otherwise have to pursue a cause of action against any person (or his/her agent) to whom this request is presented when such cause of action arises out of a response to request for information pursuant to the Indian Gaming Regulatory Act to 1988 (25 W.S.C. para 2701 et seq). I further agree to indemnify and hold harmless any person to whom this request is lawfully presented. Such indemnification and holding harmless includes all claims, damages, losses and expenses, including reasonable attorneys' fees.

A reproduction of this authorization is the same as the original.

Executed at Grand Portage Reservation, MN 55605

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