PERSONAL HISTORY RECORD & PACKET INFORMATION

ATTENTION:

1. Applicant's responsibility: Complete Fingerprint appointment, Create account in Pryme submit Gaming License application, Release form and Wage Assignment. Submit all requested paperwork court/financial if applicable. All information MUST be complete before the applicant is eligible for hire.
2. A background investigation will be completed on all applicants.

If items listed have not already been supplied, bring originals to be copied an agent. 

• Driver's License/ State ID 
• Social Security Card or Number 
• Tribal ID/ Enrollment Verification (if applicable) 
• DD214-Form 4 (Member 4)(if applicable) 
• Bankruptcy Document (if applicable) 
• Criminal Complaint & Disposition Papers ( civil and/or criminal) 
• Proof of Fines Paid (if applicable) 
• Professional License (if applicable) 
• Passport (if applicable) 
• Alien Registration or, 
• Employment Authorization Document (EAD) or, 
• Certificate of Naturalization Number (if applicable) 

Current marital I living arrangement status 

• Spouses/Co-habitant's full name, date of birth, address, home phone number, employer, and occupation, date of marriage. 
• Previous marriages (if applicable). 
• Roommate's name, date of birth, employer and occupation. 

CHILDREN/DEPENDENTS

• Children/ Step-Children/ Adopted Children/ Foster Children Full name and date of birth. 

RELATIVES/FAMILY MEMBERS

• Parents / Step-parents / Legal Guardian / Brothers / Sisters / In­-Laws                     (Be sure to list even if they are deceased)

MILITARY:

• Country I Branch of Service / Serial Number/ Date of Entry/ Date of Separation / Type of Discharge / Separation Rank (Copy ofDD214-form 4 will be made for file) 

List all pending or previous arrests/charges/convictions for the last 10 years include all misdemeanor, forfeitures including theft, fraud, misrepresentation and issue of worthless checks. List ALL Felony charges and convictions from the age of 18 or if you were a minor charged as an adult. 

You must disclose the requested information even if a charge was amended, dismissed, or you were acquitted, a conviction was stayed or vacated, prosecution was deferred, the record sealed or expunged, or you have been told you need not disclose this information. 

Include the following information: Date of Charge, Charge, Agency & Location, and Disposition. Court documentation may be required. 

List all residences for the past 10 years. 

Three character references that may be contacted during normal business hours, Monday - Friday, 8:00 a.m. - 5 :00 p.m. 

DO NOT INCLUDE FAMILY MEMBERS, COHABIT ANT, OR ROOMMATES. REFERENCES CANNOT SHARE THE SAME RESIDENTIAL ADDRESS WITH YOU OR EACH OTHER. YOU MUST PROVIDE FULL NAME/ADDRESS/CONTACT INFORMATION. 

List work history including all businesses with which you have been involved for at least the previous 5 years. You must provide address/contact information. 

CURRENT/PREVIOUS PRIVLEDGED PROFESSIONAL LICENSE HELD

FINANCIAL / INVESTMENT INFORMATION 

Date of last State and Federal income tax return was filed and for what tax year. A copy of your tax filings may be requested, but is not required at this time. 

If you have filed bankruptcy in the last 10 years, a copy of Discharge or Debtor document must be submitted to Licensing Investigator. 

If you have any of the following Tax/Unemployment warrants, Small Claims, Judgments or Liens, proof of payment plan and/or statement is required. 

All information is the property of the Ho-Chunk Nation when placed in our files. Information obtained by this office is confidential and will not be released without proper authorization. 

ALL INFORMATION MUST BE UP-TO-DATE, ACCURATE AND COMPLETE