Form 306A Manufacturer of Electronic Pull-Tab System Permit Renewal Application - Personal Information Form - Virginia

Form 306A is a Virginia Department of Agriculture and Consumer Services form also known as the "Manufacturer Of Electronic Pull-tab System Permit Renewal Application - Personal Information Form". The latest edition of the form was released in October 1, 2013 and is available for digital filing.

Download an up-to-date Form 306A in PDF-format down below or look it up on the Virginia Department of Agriculture and Consumer Services Forms website.

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Mail completed application to:
PERSONAL
VDACS
INFORMATION
Office of Charitable &
FORM
Regulatory Programs
--
Post Office Box 526
FORM 306A
Richmond, VA 23218
COMMONWEALTH OF VIRGINIA
DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES
OFFICE OF CHARITABLE & REGULATORY PROGRAMS
MANUFACTURER OF ELECTRONIC PULL-TAB SYSTEM PERMIT RENEWAL APPLICATION
PERSONAL INFORMATION FORM
GENERAL INSTRUCTIONS
A. This form is a component of the application for a Manufacturer of Electronic Pull-Tab System permit.
B. This form must be completed by each individual or owner having a 10% or greater financial interest (debt or
equity), officer, director, member or partner in the applicant. If necessary, please make copies of this section for
each person.
C. Complete this form in its entirety. If a response field or question is not applicable, please indicate "N/A".
D. Please print legibly in black ink or type all responses.
E.
If necessary, please attach relevant documents and/or explanation sheets. In doing so, please identify the
corresponding question on each document/sheet.
F.
Ensure the form is dated and signed.
G. You must submit the completed application, application fee, and, if applicable, all relevant documents and/or
explanation sheets to the mailing address above. You may also email a PDF of the completed application and
relevant documents and/or explanation sheets to michael.menefee@vdacs.virginia.gov.
PERSONAL INFORMATION FORM
Charitable Gaming Regulations requires the Department of Agriculture and Consumer Services (VDACS) to conduct a
background investigation on an applicant prior to the issuance of a Manufacturer of Electronic Pull-Tab System
permit. The investigation may include, but shall not be limited to, a criminal history search and verification of current
compliance with the Commonwealth of Virginia’s tax laws. The individual designated below hereby authorizes VDACS
to investigate all matters related to this application and hereby waives any rights or causes of action he/she may have
based upon the disclosure of otherwise confidential information.
If any individual or owner having a 10% or greater financial interest (debt or equity), officer, director, member or
partner in the applicant is domiciled outside of Commonwealth of Virginia or has resided in the Commonwealth of
Virginia for fewer than five years, then a criminal history search must be conducted by the appropriate authority in
any jurisdiction he/she has resided during the previous five (5) years.
Legal First Name
Legal Middle Name
Legal Last Name
Suffix (if applicable)
Citizenship
Social Security Number
Gender
Date of Birth (month, day, year)
SECTION A
CONTACT INFORMATION
Physical Address
City
State
Zip Code
Country
Telephone Number, including area code
Email Address
(
)
Mailing Address (if different from physical address)
City
State
Zip Code
Country
Form 306A
Page 1 of 5
Rev. 10/13
Mail completed application to:
PERSONAL
VDACS
INFORMATION
Office of Charitable &
FORM
Regulatory Programs
--
Post Office Box 526
FORM 306A
Richmond, VA 23218
COMMONWEALTH OF VIRGINIA
DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES
OFFICE OF CHARITABLE & REGULATORY PROGRAMS
MANUFACTURER OF ELECTRONIC PULL-TAB SYSTEM PERMIT RENEWAL APPLICATION
PERSONAL INFORMATION FORM
GENERAL INSTRUCTIONS
A. This form is a component of the application for a Manufacturer of Electronic Pull-Tab System permit.
B. This form must be completed by each individual or owner having a 10% or greater financial interest (debt or
equity), officer, director, member or partner in the applicant. If necessary, please make copies of this section for
each person.
C. Complete this form in its entirety. If a response field or question is not applicable, please indicate "N/A".
D. Please print legibly in black ink or type all responses.
E.
If necessary, please attach relevant documents and/or explanation sheets. In doing so, please identify the
corresponding question on each document/sheet.
F.
Ensure the form is dated and signed.
G. You must submit the completed application, application fee, and, if applicable, all relevant documents and/or
explanation sheets to the mailing address above. You may also email a PDF of the completed application and
relevant documents and/or explanation sheets to michael.menefee@vdacs.virginia.gov.
PERSONAL INFORMATION FORM
Charitable Gaming Regulations requires the Department of Agriculture and Consumer Services (VDACS) to conduct a
background investigation on an applicant prior to the issuance of a Manufacturer of Electronic Pull-Tab System
permit. The investigation may include, but shall not be limited to, a criminal history search and verification of current
compliance with the Commonwealth of Virginia’s tax laws. The individual designated below hereby authorizes VDACS
to investigate all matters related to this application and hereby waives any rights or causes of action he/she may have
based upon the disclosure of otherwise confidential information.
If any individual or owner having a 10% or greater financial interest (debt or equity), officer, director, member or
partner in the applicant is domiciled outside of Commonwealth of Virginia or has resided in the Commonwealth of
Virginia for fewer than five years, then a criminal history search must be conducted by the appropriate authority in
any jurisdiction he/she has resided during the previous five (5) years.
Legal First Name
Legal Middle Name
Legal Last Name
Suffix (if applicable)
Citizenship
Social Security Number
Gender
Date of Birth (month, day, year)
SECTION A
CONTACT INFORMATION
Physical Address
City
State
Zip Code
Country
Telephone Number, including area code
Email Address
(
)
Mailing Address (if different from physical address)
City
State
Zip Code
Country
Form 306A
Page 1 of 5
Rev. 10/13
SECTION B
RESIDENTIAL HISTORY
Please provide the physical address, including city, state and approximate time period where you resided during the
previous five (5) years.
B-1.
Physical Address
City
State
Time Period (month, year)
B-2.
Physical Address
City
State
Time Period (month, year)
B-3.
Physical Address
City
State
Time Period (month, year)
B-4.
Physical Address
City
State
Time Period (month, year)
SECTION C
EMPLOYMENT HISTORY
Beginning with your current employment, please list your employment history for the previous five (5) years.
C-1.
Full Corporate Name of Entity
Time Period (month, year)
Physical Address
City
State
Title
Description of Duties
C-2.
Full Corporate Name of Entity
Time Period (month, year)
Physical Address
City
State
Title
Description of Duties
C-3.
Full Corporate Name of Entity
Time Period (month, year)
Physical Address
City
State
Title
Description of Duties
SECTION D
LICENSE, PERMIT OR REGISTRATION INFORMATION
D-1. Do you possess a gaming license, permit, or registration issued by a
licensing authority? If yes, please attach a list including the type of
[ ] Yes - attachment included
license, the licensing authority, the license number, and the name
[ ] No
and telephone number of the appropriate contact person at the
issuing authority.
D-2. Have you ever had a gaming license, permit, or registration denied,
limited, restricted, not renewed, revoked, suspended, or subject to
an administrative proceeding? If yes, please attach an explanation
[ ] Yes - attachment included
sheet detailing the facts and circumstances concerning the matter,
[ ] No
including the name of the licensing authority, the date of each
action taken and the reason for the action.
Form 306A
Page 2 of 5
Rev. 10/13
D-3. Have you ever been employed by a company that operated as a
manufacturer, supplier, or provider of any electronic gaming
equipment or electronic non-gaming equipment in any jurisdiction
[ ] Yes - attachment included
within the United States? If yes, please attach a sheet identifying
[ ] No
the company and jurisdiction, and state whether the company had a
license, permit, or registration to manufacturer, supply, or provide
the equipment?
SECTION E
PERSONAL BACKGROUND
E-1.
Have you ever been subject to any administrative proceeding or
investigation by any gaming or tax-related regulatory agency? If yes,
[ ] Yes - explanation sheet included
please attach an explanation sheet detailing the facts and
[ ] No
circumstances concerning the matter.
E-2.
Have you ever been arrested, detained, charged, indicted, convicted,
pleaded guilty or nolo contendere, or forfeited bail concerning any
[ ] Yes - explanation sheet included
misdemeanor involving gambling, financial crimes, or any felony? If
[ ] No
yes, please attach an explanation sheet detailing the facts and
circumstances concerning the matter.
E-3.
Have you ever been delinquent or in dispute with a government
agency over the payment of any debt or tax in the past ten years? If
[ ] Yes - explanation sheet included
yes, please attach an explanation sheet detailing the facts and
[ ] No
circumstances concerning the matter.
E-4.
Have you ever been party to any lawsuit (other than divorce
[ ] Yes - explanation sheet included
proceedings)? If yes, please attach an explanation sheet detailing the
[ ] No
facts and circumstances concerning the matter.
E-5.
Currently, are you a known party to any administrative proceeding,
criminal case, investigation or lawsuit (other than divorce
[ ] Yes - explanation sheet included
proceedings)? If yes, please attach an explanation sheet detailing the
[ ] No
facts and circumstances concerning the matter.
E-6.
Are you currently or have you ever knowingly been associated
professionally with persons known to be convicted of a felony
[ ] Yes - explanation sheet included
involving gambling or financial crime? If yes, please attach an
[ ] No
explanation sheet detailing the facts and circumstances concerning
the matter.
E-7.
Have you requested that a criminal history search be conducted by
the appropriate authority in each jurisdiction you have resided
during the previous five (5) years? Please request that the
jurisdiction send the results of the criminal history search directly to
the following address:
[ ] Yes
Office of Charitable & Regulatory Programs
[ ] No – explanation sheet included
Attn: Program Manager
Post Office Box 1163
Richmond, VA 23218
If no, please attach an explanation sheet detailing the reason.
E-8.
Please attach a signed copy of the ‘Authority to Release Information
[ ] Attachment included
Form,’ which is located at the end of this application.
Form 306A
Page 3 of 5
Rev. 10/13
SECTION F
FINANCIAL INTEREST
F-1.
During the previous five years, have you had a business relationship
with or financial interest (debt or equity) in any gaming-related
activity, business, equipment or facility, other than the applicant or
[ ] Yes - explanation sheet included
otherwise disclosed in section C of this form? If yes, please attach an
[ ] No
explanation sheet identifying the business relationship, or the
amount of the financial interest, percentage of it, and the nature of
the instrument.
DISCLAIMERS AND AFFIDAVITS
By completing this form and affixing my signature, I hereby state that to the best of my knowledge, information and
belief that there has been no misrepresentation or failure to disclose. I am aware that later discovery of an omission or
misrepresentation made in this form, or made on any statement, document, or information may be grounds for denial
of the applicant’s application or revocation of the applicant’s permit, or subject the applicant or personnel to criminal
penalties in the Commonwealth of Virginia.
I agree that I will notify the Office of Charitable and Regulatory Programs of any circumstance that necessitates
amending any response provided in this form.
I agree that I will abide by the laws and regulations governing charitable gaming in the Commonwealth of Virginia.
Signature
Date
Form 306A
Page 4 of 5
Rev. 10/13
AUTHORITY TO RELEASE INFORMATION FORM
I, ___________________________________________ authorize and grant my consent to permit any law
enforcement agency, and any other person, business or agency deemed necessary, to release any information
requested by any identified official from the Virginia Department of Agriculture and Consumer Services.
This information is for the express purpose of determining my eligibility to obtain a permit as a manufacturer of
electronic pull-tab systems issued under the authority of the Virginia Charitable Gaming Statutes.
Full Corporate Name of Entity
Doing Business As/Trading As Name
Date
Signature
Title
NOTARY STATEMENT
Sworn and subscribed before me this ________ day of _________________________, 20_____ in the (county / city)
_______________________________________in the state of ____________________________________.
Notary’s Signature
Notary’s Printed Name
Notary’s Commission Number
Notary’s Commission Expiration Date
Form 306A
Page 5 of 5
Rev. 10/13
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