Personal Criminal History Statement Form. This is a Montana form and can be use in Department Of Revenue Statewide.
Tags: Personal Criminal History Statement, 10, Montana Statewide, Department Of Revenue
Print Form PERSONAL/CRIMINAL HISTORY STATEMENT Please type or print clearly in dark ink. Complete all spaces or print N/A in spaces that do not apply. TYPE OF LICENCE YOU WISH TO OBTAIN: (Check all that apply) GAMBLING OPERATOR LIQUOR OPERATOR MANUFACTURER DISTRIBUTOR ROUTE OPERATOR CARD DEALER CARD ROOM CONTRACTOR SPORTS TAB SELLER NON-INSTITUTIONAL LENDER (NIL) OTHER _________________________________ POSITION WITH BUSINESS: (Check all that apply) OWNER SHAREHOLDER PARTNER MANAGER OFFICER DIRECTOR OTHER ________________________________ MEMBER LLP MEMBER LLC NAME: (Last, First, Middle) Maiden SOCIAL SECURITY NUMBER: HOME MAILING ADDRESS: (Street or PO Box) City County HOME PHONE: WORK/CELL PHONE: WEIGHT: EYE COLOR: HAIR COLOR: RACE: DRIVER’S LICENSE NUMBER & STATE OF ISSUE: Zip Code: State or Country: HOW LONG LIVING AT HOME ADDRESS ABOVE: HEIGHT: BIRTHDATE: (Month, Day and Year) ARE YOU A U.S. CITIZEN? SEX: MALE FEMALE PORT OF ENTRY: DATE OF ENTRY: (Month, Day and Year) Maiden If NO, give alien registration/entry visa/work permit number(s): DATE OF MARRIAGE: (Month, Day and Year) YES NO SPOUSE’S NAME: (Last, First, Middle) LICENSE HISTORY List any business licenses that you have ever held, currently applied for, or have been denied/revoked/suspended in any state. If more space is needed, attach additional sheets in the same format. TYPE LICENSE NUMBERS BUSINESS NAME STATE LAST YEAR HELD GAMBLING LIQUOR OTHER CRIMINAL HISTORY STATEMENT Circle Y (yes) or N (no) to answer whether you have EVER: 1. Been arrested? Y/N 2. Been charged with a crime? Y / N 3. Been convicted? Y / N 4. Been Jailed? Y/N 5. Been placed on probation? Y / N 6. Forfeited bail or paid a ﬁne over $25 (Exclude trafﬁc offenses except DUI and Reckless Driving)? Y / N You must answer "YES" if any of the above have occurred, EVEN IF CHARGES WERE DISMISSED, DEFERRED OR CHANGED. Explain each charge fully below and attach additional sheets as needed. False or incomplete information may result in denial, suspension or revocation of a license. If more space is needed, attach additional sheets in the same format. OFFENSE DATE OFFENSE CITY COUNTY STATE DISPOSITION AND DATE CONFIDENTIAL LITIGATION HISTORY Have you, as an individual, member of a partnership, or owner, director, or ofﬁcer of a corporation, ever been a party to a lawsuit. YES NO If yes, give details below. List all cases without exception, including bankruptcies. If more space is needed, attach additional sheets in the same format. PLAINTIFF/DEFENDANT FORM 10 REV 07/11 COURT AND CASE NUMBER CITY COUNTY STATE DISPOSITION Continue on to page 2 of this form. American LegalNet, Inc. www.FormsWorkFlow.com PERSONAL/CRIMINAL HISTORY STATEMENT (Page 2) EMPLOYMENT HISTORY List employment, self-employment, military, unemployment and school attendance for the last 10 consecutive years (include foreign residences). If more space is needed, attach additional sheets in the same format. Dates From - To: TITLE: SUPERVISOR: EMPLOYER/SCHOOL: REASON FOR LEAVING: ADDRESS: (Street or Route) Dates From - To: City County TITLE: REASON FOR LEAVING: ADDRESS: (Street or Route) City County TITLE: State or Country Zip Code SUPERVISOR: EMPLOYER/SCHOOL: ADDRESS: (Street or Route) Zip Code SUPERVISOR: EMPLOYER/SCHOOL: Dates From - To: State or Country REASON FOR LEAVING: City County Have you ever been ﬁred or asked to resign from any employment related to gambling Yes No State or Country Zip Code If yes, explain: ___________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ RESIDENCE INFORMATION You must list all places of residence for the last 10 consecutive years (include foreign residences). List current residence ﬁrst. If more space is needed, attach additional sheets in same format. Dates From - To: STREET ADDRESS: CITY: Dates From - To: COUNTY: STATE OR COUNTRY: ZIP CODE: COUNTY: STATE OR COUNTRY: ZIP CODE: STREET ADDRESS: CITY: CERTIFICATION AND AUTHORIZATION "I certify under penalty of law that all answers and statements on page 1 and 2 are true, correct and complete. I understand that untruthful or misleading answers are cause for denial of a license and/or revocation of any license granted. I hereby authorize the Gambling Control Division to investigate my criminal history, financial records and other sources as necessary for licensing." The Montana Department of Justice Gambling Investigation Bureau shall access and review State and Federal history records and shall make reasonable efforts to make a determination whether you have been convicted of, or are under pending indictments for a crime that bears upon your ﬁtness to be granted a license. You are entitled to (a) obtain a copy of any background check report and (b) challenge the accuracy and completeness of any information contained in any such report and obtain a prompt determination as to the validity of such challenge before a ﬁnal determination is made by the Montana Department of Justice Gambling Investigation Bureau. Such a request for a copy of your criminal history record and any challenge to the accuracy of such record should be addressed to the Montana Department of Justice Gambling Investigation Bureau. SIGNATURE: X PRINT NAME: FORM 10 REV 07/11 DATE SIGNED: PLACE SIGNED: (City, County and State) American LegalNet, Inc. www.FormsWorkFlow.com