Casino License Application Form

Casino License Application Form

This Casino License Application is submitted on Month Day Year by Applicant Name: whose principal business address is . Applicant submits this application to Licensing Authority Name: located at .

RECITALS

WHEREAS, Applicant seeks a license authorizing the operation of a gaming establishment offering table games, slot machines, sports wagering, or other authorized gaming activities at the proposed location; and

WHEREAS, Licensing Authority is empowered under applicable statute and regulation to receive, investigate, adjudicate, grant, condition, suspend, revoke, or deny licenses for gaming operations and to impose requirements to protect the public interest; and

WHEREAS, Applicant submits representations, disclosures, and supporting materials in reliance on statutory and regulatory requirements and acknowledges that the grant of a license is conditioned upon the truthfulness and completeness of all statements and materials submitted.

NOW THEREFORE, in consideration of the mutual covenants and representations herein, Applicant applies for a Casino License under the terms and conditions set forth below.

1. APPLICATION DETAILS

Slot machines    Table games    Sports wagering    Poker    Other:

2. ENTITY STATUS AND CONTROL

Entity Type: Corporation LLC Partnership Sole proprietorship Other:

3. OWNERSHIP DISCLOSURE

Applicant must disclose all persons and entities holding a direct or indirect ownership or control interest of five percent (5%) or more. Attach additional sheets if necessary and provide current citizenship and principal residence for each disclosed owner.

4. FINANCIAL INFORMATION

Applicant shall provide audited financial statements for the most recent three fiscal years and pro forma capitalization demonstrating sufficient funds to construct, outfit, and operate the proposed casino for at least twelve months without operating revenue.

5. BACKGROUND, SUITABILITY AND CRIMINAL HISTORY

Applicant certifies that it will submit to background investigations and fingerprinting for all principals, officers, and persons required by statute or regulation. The Licensing Authority may deny a license for convictions, regulatory sanctions, financial improprieties, or material omissions.

Yes    No

6. OPERATIONS PLAN

7. FEES, BONDING, TAXES

Applicant acknowledges that payment of application fees, regulatory assessments, and any required bond or surety is a condition precedent to issuance of a license. The Licensing Authority may impose periodic assessments and taxes as authorized by law.

8. INSPECTIONS, COMPLIANCE, RECORDS

Applicant agrees to permit authorized representatives of Licensing Authority to inspect premises, records, surveillance footage, and gaming equipment at reasonable times. Applicant shall maintain complete books, records, and electronic data as required by statute and regulation.

9. GROUNDS FOR SUSPENSION OR REVOCATION

The Licensing Authority may suspend, condition, or revoke any license for material misrepresentation, fraud, failure to pay taxes or assessments, conviction of a disqualifying offense, failure to comply with regulatory requirements, or conduct adverse to the public welfare. Applicant acknowledges these grounds and consents to regulatory action where supported by evidence.

10. CERTIFICATIONS AND ATTESTATIONS

By signing below, Applicant certifies under penalty of perjury that all information provided in this application and attached exhibits is true, correct, and complete. Applicant acknowledges that false statements, omissions, or material misrepresentations are grounds for denial, suspension, or revocation of the license and may subject the signatory to civil or criminal penalties.

11. NOTICES

All notices required or permitted under this application shall be delivered in writing to the addresses provided below. Notice is effective upon receipt as delivered in person, by courier, or by certified mail when mailed to the designated address.

12. AMENDMENTS; WAIVER

Any amendment to this application or any waiver of the requirements set forth herein must be in writing and signed by an authorized representative of the Licensing Authority and the Applicant. No failure or delay by the Licensing Authority in exercising any right constitutes a waiver of that right.

13. GOVERNING LAW

This application, and any license issued in reliance upon it, shall be governed by the laws and regulations of the state or jurisdiction in which the proposed gaming establishment is located, and by the rules promulgated by the Licensing Authority.

14. ENTIRE AGREEMENT

This application, together with required attachments and exhibits, constitutes the entire understanding between Applicant and the Licensing Authority with respect to the matters set forth herein and supersedes all prior representations and agreements, whether written or oral.

15. SEVERABILITY

If any provision of this application or any attachment is held to be invalid or unenforceable, the remaining provisions shall remain in full force and effect to the extent permitted by law.

16. APPLICANT ATTESTATION

I, the undersigned, am an authorized representative of Applicant and hereby declare under penalty of perjury that the information contained in this application and accompanying documentation is true, complete, and accurate to the best of my knowledge, and that I understand that willful misstatements or omissions may subject me to criminal or civil penalties and license sanctions.

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