Fill and Sign the Cayman First Insurance Forms 41530882

VENDOR LICENSE APPLICATION CERTIFICATION I certify that I am duly authorized officer or owner of the applicant with knowledge and authority to provide the above information and to act on behalf of this business entity, and that to the best of my knowledge and belief the foregoing information is true, accurate, and complete as of the date of this application. I understand that untruthful or misleading answers are cause for denial of the application and/or revocation of any gaming license granted. I further understand that this business has a continuing duty to provide all materials, assistance, or information required by the Poarch Band of Creek Indians Tribal Gaming Commission, including any information that may be requested from business owners, shareholders, directors, officers, or other key personnel; and to fully cooperate in any investigation conducted by or on their behalf. If any information provided on this application changes or otherwise becomes inaccurate, or new information becomes available, I agree to promptly notify the Poarch Band of Creek Indians Tribal Gaming Commission with or without a formal request for such information. Applicant Name:____________________________________________________________________________ Signature:________________________________________ Title:_______________________________ Printed Name:_____________________________________ Date:_______________________________ Sworn to and subscribed before me on this the ______ day of _______________, 20_____. ________________________________________________ Notary Public in and for the State of __________________ Printed Name:____________________________________ My commission expires:____________________________ Vendor License Application RELEASE I,______________________________________________, as the authorized representative acting on behalf of the business listed below (Applicant), am filing with the Poarch Band of Creek Indians Tribal Gaming Commission this application for a gaming license. In consideration of the assurances by the Poarch Band of Creek Indians Tribal Gaming Commission that no action on this application will be taken except after a complete investigation, I hereby for myself, the business entity, and its successors and assigns, release, remise, and discharge the Poarch Band of Creek Indians, the Poarch Band of Creek Indians Tribal Gaming Commission, and their respective members, agents, and employees from any and all causes of action, suits, debts, judgments, executions, claims, and demands, known or unknown, in law or equity, which this business had, now has, or may claim to have against the Poarch Band of Creek Indians, the Poarch Band of Creek Indians Tribal Gaming Commission, or their agents or employees, arising out of or by reason of the processing or investigation of or other action relating to this gaming license application. I, as an authorized representative acting on behalf of Applicant, have read this release and understand all of its terms and execute it voluntarily and with full knowledge of its significance. In witness whereof, I have _______________________, 20_____. executed this release on the _____________ day of Applicant Name:____________________________________________________________________________ Signature:________________________________________ Title:_______________________________ Printed Name:_____________________________________ Date:_______________________________ Sworn to and subscribed before me on this the ______ day of _______________, 20_____. ________________________________________________ Notary Public in and for the State of __________________ Printed Name:____________________________________ My commission expires:____________________________ 2 Vendor License Application RELEASE OF INFORMATION AUTHORIZATION I, ______________________________________________, as the duly authorized representative acting on behalf of the business entity (Applicant) listed below, hereby authorize any investigator, agent or representative of the Poarch Band of Creek Indians Tribal Gaming Commission or any other tribal, federal, or state gaming or law enforcement or investigatory agency and their authorized agents, in order to determine Applicant’s suitability for involvement in Indian gaming activities to obtain any and all information and records requested related to my activities, including any personal, business, criminal or financial information, credit history, court records, tax records, and the like. Sources of such records and information may include, but are not limited to, financial or lending institutions, businesses, regulatory agencies, credit bureaus, and other sources, whether or not such information would otherwise be protected from disclosure by law or privilege. I authorize custodians of such records and sources of information to release such documents, records, correspondence, and information, and to permit the review and copying of any and all documents, reports, records, correspondence, and information pertaining to this business, upon request of a representative of the Poarch Band of Creek Indians Tribal Gaming Commission, regardless of any previous agreement to the contrary. I hereby agree to release, remise, indemnify, and hold harmless any person or entity to whom this request is presented, and their agents and employees, from and against any and all manner of action, causes of action, suits, debts, judgments, executions, claims, expenses, and demands whatsoever, known or unknown, in law or equity, which I ever had, now have, may have, or may claim to have against such person or entity or their agents and employees arising out of or by reason of complying with this request. I understand and 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 any purpose listed in this document. I understand that the information and records released by records custodians and other sources of information is for the purpose of conducting a background investigation to process the license or license renewal application of this business for the purposes of providing goods, services, or financing in conjunction with gaming activities, operations, or regulation and that all information collected shall be held in strict confidence by the Poarch Band of Creek Indians Tribal Gaming Commission, used solely for the purpose of gaming license suitability. Copies of this authorization that show my signature are as valid as the original. 3 Vendor License Application In witness whereof, I have _______________________, 20_____. executed this release on the _____________ day of Applicant Name:____________________________________________________________________________ Signature:________________________________________ Title:_______________________________ Printed Name:_____________________________________ Date:_______________________________ Sworn to and subscribed before me on this the ______ day of _______________, 20_____. ________________________________________________ Notary Public in and for the State of __________________ Printed Name:____________________________________ My commission expires:____________________________ 4