Virgin Islands Casino Control Commission
3005 Orange Grove 
Christiansted, VI  00820-3005 
(340) 718-3616 ext. 240 • (340) 718-3136 fax 
 info@casinocontrolcommission.vi 
 
 
 
 
CASINO EMPLOYEE LICENSE APPLICANT CHECKLIST 
 
   Personal History Disclosure Form 2.  Applicant must answer every question completely  
 
   Statement of Truth, Release of all Claims, and Release Authorization must be notarized 
 
THE FOLLOWING DOCUMENTATION ARE REQUIRED FOR INITIAL APPLICATION 
 
   Fingerprint card 
 
   VIPD Background check 
 
   2 passport size pictures 
 
   2 Government issued I.D. (i.e., V.I. Driver’s license, Passport and/or Voter’s I.D.) 
 
   Birth Certificate 
 
   Naturalization Document or U.S. Passport 
 
   Offer letter 
 
   Tax documents (last 3 years) 
 
    Social Security Card 
 
   High School Diploma 
 
 
THE FOLLOWING DOCUMENTATION ARE REQUIRED FOR RENEWAL APPLICATION 
 
   Personal History Disclosure Form 2 – Renewal.  Applicant must answer every question completely 
 
   Fingerprint card 
 
   Background check 
 
   2 passport size pictures 
 
   Tax documents (last 3 years) 
 
 
RENEWAL 
PERSONAL IDSTORY DISCLOSURE FORM 2 
APPLICATION INSTRUCTIONS 
1.
You are to complete this application if you are:
a.
An applicant for a renewal 3-year casino employee license; or
b.
An applicant for a renewal 3-year gaming school employee license; or
c.
Directed to do so by the Casino Control Commission (Commission).
2.
Read this entire form carefully before  answering any of the questions.
3.
Answer every question completely and truthfully. DO NOT LEA VE ANY BLANK SPACES. If a question 
does not apply to you, indicate "Does not apply" in response to that question. If there is nothing to disclose 
to a particular question, state "None" in response to that question.
4.
All entries on this form, except signature, must be typed or block printed in black ink. If your application 
not legible, it will not be accepted.
5.
Initial each page of this form in the space provided after you have checked your answers and are sure they 
are complete and correct.
6.
Sign the License Conditions, Release Authorization and Release of all Claims Forms in the presence of a 
Notary Public.
7.
Attach to this form complete copies of all federal, territorial, state and municipal income tax returns filed by 
you and your spouse for the last three (3) years.
8.
Submit an original and one (1) copy of this entire form to the U.S. Virgin Islands Casino
Control Commission.
9.
Once filed, you may not withdraw your application without the permission of the U.S.
Virgin Islands Casino Control Commission.
10.
We recommend that you keep a copy of your completed application for your records.  
8/2002 
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PHD2-Renewal 
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2.
Have you lived in the U.S. Virgin Islands continuously for (5) years or more? __ Yes
No 
If answer is no, state how long you have lived continuously in the U.S. Virgin Islands: ___ _ 
3.
Beginning with your current residence(s) and working backwards, provide the following
information with respect to each place where you have lived during the past four years.
TELEPHONE 
DATES 
ADDRESS 
NUMBER 
(No., Street, Apt., City, State, Country & Zip Code) 
FROM: 
TO: 
<MO/YR) 
<MO/YR) 
4.
Circle your current marital status: Single Engaged 
Married Legally Separated Divorced Widowed
5.
Give the name and current address of your present spouse:
6.
If you have been separated, annulled or divorced, f"lll in the information below for each and every
action.
Separated, Annulled or Divorced 
8/2002 
PHD2-Renewal 
Date of Such 
Action 
Name and Address of Court and State of Issuance 
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7.
Provide the information listed below with respect to each school, college, graduate or post graduate
school, vocational or other employment training program which you have attended within the last
four ( 4) years. Be sure to include participation in certified Territorial casino gaming courses. If
applicable and available, attach a copy of your graduation certificate from the gaming school
attended.
DATES 
FROM: 
<MO/YR) 
8/2002 
PHD2-Renewal 
TO: 
<MO/YR) 
NAME AND ADDRESS OF 
SCHOOL, TRAINING 
PROGRAM, ETC. 
4 
DESCRIPTION OF 
LIST ANY DEGREE 
EDUCATIONAL 
OR CERTIFICATION 
PROGRAM 
ATTAINED 
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8.
Provide the information listed below as to each place in which you have been employed for the
past four ( 4) years. Begin with your present job and work backwards. Give dates of any
unemployment between jobs in proper sequence. Include all part-time and full-time employment
and any military service. Note by means of an asterisk (*) any gaming-related employment (such as
casino gaming, Internet gaming, horse racing or parimutuel operation, lottery, sports betting, etc.)
DATES 
NAME, MAILING ADDRESS 
TITLE, POSITION HELD 
REASON FOR 
AND PHONE NUMBER OF 
AND DESCRIPTION OF 
LEAVING 
EMPLOYER(S). INCLUDE 
DUTIES 
FROM: 
TO: 
NAME OF IMMEDIATE 
(MO/YR MO/YR 
SUPERVISOR. 
9.
Within the past four (4) years have you applied in any other jurisdiction for a license, permit or
other authorization to participate in a lawful gambling operation (including casino gaming, horse 
racing, parimutuel operation, lottery, sports betting, etc.?)        Yes         No. If yes, complete the 
following chart:
TYPE OF 
GAMBL_ING 
APPROVAL 
8/2002 
PHD2-Renewal 
POSITION 
DATE OF 
SOUGHT OR 
APPLICATION 
HELD 
NAME AND ADDRESS 
DISPOSITION 
IF ISSUED, GIVE 
OF LICENSING 
(GRANTED, 
APPROPRIATE 
AGENCY 
DENIED OR 
NUMBERS 
(INCLUDE COUNTRY, 
PENDING) 
STATE, COUNT OR 
MUNICIPALITY) 
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10.
Within the past four (4) years have you had any license, permit or certificate denied, suspended or
revoked by any governmental agency? (Do not include driver's license.)           Yes              No  Hyes, 
complete the following chart:
TYPE OF LICENSE, 
NAME & ADDRESS OF 
DATE OF DENIAL, 
REASON(S) FOR 
PERMIT OR 
GOVERNMENTAL 
SUSPENSION OR 
DENIAL, 
CERTIFICATE 
AGENCY 
REVOCATION 
SUSPENSION OR 
REVOCATION 
Question #11 asks about any arrests, charges or offenses you may have committed. Prior to answering this 
question, carefully review the definitions and instructions which follow. For purposes of this question: 
DEFINITIONS 
A.
"Arrest" includes any detaining, holding or taking into custody by any police or other law
enforcement authorities to answer for the alleged performance of any "offense."
B.
"Charge" includes any indictment, complaint, information, summons, or other notice of the
alleged commission of any "offense."
C.
"Offense" includes all ctjmes, felonies, misdemeanors, disorderly conduct offenses and any
other types of offenses.
INSTRUCTIONS 
1.
Answer "YES" and provide all information to the best of your ability EVEN IF:
8/2002 
PHD2-Renewal 
A.
You did not commit the offense charged;
B.
The charges were dismissed
C.
You completed a Pretrial Intervention Program (PIP) or equivalent
diversionary program in any jurisdiction;
D.
You were not convicted;
E.
You did not serve any time in prison or jail; or
F.
The charges or offenses happened a long time ago.
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I 
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2.
Answer "NO" IF:
A.
The records relating to the arrest or charges have been expunged or sealed by
court order; AND
B.
You attach a copy of the expungment or sealing order to this application.
11.
Within the past four (4) years, have you been arrested or charged with any crime or offense (other
than a traffic violation) in this Territory or anywhere else?           Yes 
No     Hyes, complete 
the following chart:
NATURE OF 
DATE OF 
NAME AND ADDRESS OF 
DISPOSITION 
SENTENCE 
CHARGE OR 
CHARGE OR 
LAW ENFORCE:MENT 
(CONVICTED, 
ARREST 
ARREST 
AGENCY OR COURT 
ACQUITTED, 
INVOLVED 
DISMISSED, PENDING, 
PARDONED. ETC.) 
12.
Within the past four (4) years, have you been called to testify before, been the subject of an
investigation conducted by, or requested to take a polygraph exam by any governmental agency, 
court, committee, grand jury or investigatory body (municipal, state, territory, county, provincial, 
federal, national, etc.) other than in response to a traffic summons?            Yes            No     Hyes,
complete the following chart:
NAME AND ADDRESS OF 
COURT OR OTHER 
AGENCY 
8/2002 
PHD2-Renewal 
NATURE OF 
WAS 
PROCEEDINGS OR 
TESTIMONY 
INVESTIGATION 
GIVEN 
7 
DATE ON 
APPROXIMATE 
WHICH 
TIME PERIOD 
TESTIMONY 
OF 
WAS GIVEN 
INVESTIGATION 
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13.
a)
Within the past four (4) years have you been a party to a lawsuit? (Include 
matrimonial matters, negligence matters, auto accident matters, contract matters, collection 
matters, debt matters, etc.)           Yes               No 
b)
Within the past four (4) years have you had any financial liens filed against you? (include
federal tax liens, employment judgments, defaulted student loans, etc.)        Yes             No  
Hyes to either question, complete the following chart:
DATE 
JURISDICTION 
DOCKET 
OTHER 
NATURE 
DISPOSITION 
DATE OF 
FILED 
NUMBER 
PARTIES TO 
OF SUIT 
DISPOSITION 
SUIT 
14.
During the past four (4) years, have you or your spouse held a ten percent (10%) or more ownership
interest in or been a director, officer or principal employee of any corporation, partnership, sole 
proprietorship, or other business entity that has held a foreign bank account or that has had the 
authority to control disbursements from a foreign bank account?          Yes             No • Indicate if 
self or spouse.
8/2002 
PHD2-Renewal 
8 
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15.
Within the past four (4) years, have you held an ownership interest in any business (es)? (Do not
include publicly traded corporations in which you owned stock.)              Yes              No
H yes, beginning with the most recent and working backwards, provide the following information 
with regard to all business(es) in which you have held an ownership interest. 
DATES 
NAME(S)AND 
CURRENT 
% OF INTEREST 
NAME(S)OF 
ADDRESS(ES) OF 
STATUS OF 
HELD BY YOU 
OTHER 
FROM: 
TO: 
BUSINESS(ES) 
BUSINESS(ES) 
OWNER(S) 
(MO/YR 
<MO/YR 
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16.
Within the past four (4) years have you personally been adjudicated bankrupt or filed a petition for
any type of bankruptcy or insolvency under any bankruptcy insolvency law ?           Yes              No      
If yes, attach a copy of the bankruptcy petition and discharge, if granted. H yes, also complete the 
following chart:
DATE FILED 
8/2002 
PHD2-Renewal 
DOCKET NUMBER 
NAME & ADDRESS OF 
COURT 
9 
NAME AND ADDRESS 
OF TRUSTEE 
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17.
Within the past four (4) years has any business entity in which you held 10% or greater ownership
(other than ownership ofstock in a publicly traded corporation) or in which you served as an officer
or director been adjudicated bankrupt or filed a petition for any type of bankruptcy or insolvency
under any bankruptcy or insolvency law?            Yes 
     No   Hyes, complete the following chart:
DATE 
DOCKET 
NAME & ADDRESS OF 
NAME & ADDRESS OF 
NAME & ADDRESS 
FILED 
NUMBER 
COURT 
FILING PARTY 
OF TRUSTEE 
18.
Within the past four (4) years have your wages, earnings, or other income been subject to
garnishment, attachment, charging order, voluntary wage execution or the like?         Yes            No        
H yes, complete the following chart:
DATE 
FILED 
8/2002 
PHD2-Renewal 
DOCKET 
NAME & ADDRESS OF 
NUMBER 
COURT 
10 
NATURE OF 
AMOUNT OF 
NAME& 
OBLIGATION 
OBLIGATION 
ADDRESS OF 
HOLDER OF 
OBLIGATION 
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19. Do you have any bank accounts or safe deposit boxes in your name?           Yes                 No
Do you have access to the funds in any other bank accounts or safe deposit boxes?           Yes              No 
Hyes to either question, complete the following chart:
NAME & ADDRESS OF 
NAME(S) IN WHCH 
TYPE OF ACCOUNT, 
ACCOUNT NO. 
BANK 
ACCOUNT(S) OR SAFE 
(SAVINGS, CHECKING, 
OR SAFE 
DEPOSIT BOX(ES) HELD 
SAFE DEPOSIT, ETC.) 
DEPOSIT BOX 
NO. 
20.
State when you filed your last Federal Income Tax Return Form 1040, to what Internal Revenue
Service Center it was sent and the tax period covered.
Date Filed:
Period Covered:
IRS Office Location:
Attach to the back of this form and label as Exhibit 20 complete copies of all federal, state,
territorial and municipal Income Tax Returns filed within the past three (3) years.
8/2002 
PHD2-Renewal 
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Initials __ _ 
LICENSE APPLICATION CONDITIONS 
By the signing of this application, the applicant entity acknowledges that the laws of the Virgin Islands and the 
United States, as applicable, shall apply to the conduct of its operations and that the applicant shall comply with 
all rules and regulations promulgated by the Commission. 
The applicant entity also acknowledges that, if a license be granted, it will become the duty of the 
applicant/licensee to file with the U.S. Virgin Islands Casino Control Commission ("Commission") such reports 
and financial data as may be required by Territorial Statute or by such rules and regulations as the Commission 
has adopted or may hereafter adopt, and to make such payments and/or fees as may be required by law. The 
aforementioned duty shall continue for the entire term (duration) of the license. H the applicant/licensee fails to 
abide by these requirements, the applicant/licensee shall incur the penalties set forth in the U.S Virgin Islands 
Code or in such rules and regulations as the Commission has adopted or may hereafter adopt. 
Applicant entity verifies that all exhibits, statements, reports, papers, data, etc. submitted pursuant to this 
application are true, complete and current. The applicant entity additionally agrees to THEREAFTER provide 
the Commission with full description of any significant operational change in any of the aforementioned exhibits, 
statements, reports, papers, data, etc. as said change occurs. 
Applicant entity hereby consents to all inspections, searches and seizures and the supplying of handwriting 
exemplars as authorized by 32 VIC 432(c). 
Applicant entity agrees that any license which may hereafter be granted to said individual or entity is predicated 
upon the statements and answers herein contained, which may be subject to verification by the Division of Gaming 
Enforcement or the Commission. 
Applicant entity verifies that the above statements are true and correct to the best of his/her knowledge and belief, 
and that this application is executed with the knowledge that any misrepresentation or failure to reveal 
information requested may be deemed sufficient cause for the refusal to issue, or revocation of, a license. Further, 
that said applicant entity is voluntarily submitting this statement and understands that misleading statements may 
subject applicant entity to criminal or other sanctions or punishment. 
I/We have read the application, attached instructions and above paragraphs, and agree to the conditions as set 
forth. 
Subscribed and sworn to before me this 
…††‡day of††ˆ†- -††-
Notary Public 
Commission Expiration Date 
SEAL 
8/2002 
PHD2-Renewal 
By 
12 
Signature 
Applicant Entity 
Title 
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SIGN