DEAR APPLICANT: This questionnaire has been prepared in compliance with
the Privacy Act of 1974. Solicitation of the information on this form is
authorized by 25 United States code, Section 2701 et seq. The purpose is
to determine the eligibility of individuals to be employed by a gaming
facility. Members of the National Indian Gaming Commission and staff may
review this information. Some portions may be disclosed to appropriate
federal, tribal, state, local, or foreign law enforcement and regulatory
agencies when relevant to a civil, criminal or regulatory investigation
or prosecution. Various data may be required by management, the Tribal
Gaming Commission or the National Indian Gaming Commission in connection
with the hiring and firing of an employee, the issuance or revocation of
a gaming license, or investigations of activities while the applicant was
associated with a tribe or gaming operation. Failure to answer any questions
on this form may result in the tribe being unable to hire you as a casino
employee. A false statement or omission of material fact on any part of
this application may be grounds for not hiring you or for discharging you
after you commence employment. Furthermore, you may be subject to fines
and/or imprisonment. (Title 18, Untied States code, Section 1001). The
disclosure of your Social Security Number (SSN) is voluntary. However,
your failure to supply a SSN may result in errors in processing your application.