Form CGCC-CH1-01 "Notice of Contact Information Change" - California

What Is Form CGCC-CH1-01?

This is a legal form that was released by the California Gambling Control Commission - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2021;
  • The latest edition provided by the California Gambling Control Commission;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CGCC-CH1-01 by clicking the link below or browse more documents and templates provided by the California Gambling Control Commission.

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Download Form CGCC-CH1-01 "Notice of Contact Information Change" - California

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State of California
California Gambling Control Commission
Notice of Contact Information Change
CGCC-CH1-01 (Rev. 01/21)
Page 1 of 1
MAIL COMPLETED FORM TO:
BUREAU OF GAMBLING CONTROL
P.O. Box 168024
Sacramento, CA 95816-8024
(916) 830-1700
PLEASE READ THE FOLLOWING INFORMATION CAREFULLY BEFORE YOU COMPLETE THIS FORM
Complete this form to notify the Bureau of Gambling Control (Bureau) of a change in contact information (as required in Title 4,
CCR, Section 12004). To notify the Bureau of the physical relocation of a gambling establishment, please use form Notice of
Relocation, CGCC-CH7-02 (Rev 01/21).
Please note: To change your name you must submit a Badge Replacement Request
All information must be typed or printed legibly in blue or black ink.
SECTION 1: INFORMATION
NAME
LICENSE/PERMIT NUMBER, IF APPLICABLE
REQUESTOR
Cardroom Business Licensee
Cardroom Endorsee Licensee
Key Employee Licensee
Commission Work Permitee
TPPPS Business Licensee
TPPPS Endorsee Licensee
TPPPS Supervisor Licensee
TPPPS Worker Licensee
Manufacturer or Distributor
Designated Agent
Other: ____________________
SECTION 2: CHANGE IN CONTACT INFORMATION
Check each appropriate box and fill out all information as applicable.
NEW RESIDENCE/PHYSICAL OFFICE ADDRESS (STREET, CITY, STATE, ZIP CODE)
NEW MAILING ADDRESS IF DIFFERENT THAN NEW OR CURRENT RESIDENCE (STREET, CITY, STATE, ZIP CODE)
NEW PRIMARY NUMBER:
NEW ALTERNATIVE PHONE NUMBER:
NEW FAX NUMBER:
NEW EMAIL ADDRESS:
SECTION 3: DECLARATION
I declare under penalty of perjury under the laws of the State of California that the information in this form is true, accurate, and complete, and that
this declaration is executed by me at
.
City and State
PRINTED NAME
SIGNATURE
DATE (MM/DD/YYYY)
This form must be signed by the appropriate person identified below:
 If applicant/licensee is a corporation, LLC, or joint venture then by an authorized officer.
 If applicant/licensee is a general partnership or limited partnership then by an authorized partner.
 If applicant/licensee is a sole proprietor then by the owner.
 If applicant/licensee is a trust then by an authorized trustor or trustee.
 If applicant/licensee is a natural person then by the applicant/licensee.
State of California
California Gambling Control Commission
Notice of Contact Information Change
CGCC-CH1-01 (Rev. 01/21)
Page 1 of 1
MAIL COMPLETED FORM TO:
BUREAU OF GAMBLING CONTROL
P.O. Box 168024
Sacramento, CA 95816-8024
(916) 830-1700
PLEASE READ THE FOLLOWING INFORMATION CAREFULLY BEFORE YOU COMPLETE THIS FORM
Complete this form to notify the Bureau of Gambling Control (Bureau) of a change in contact information (as required in Title 4,
CCR, Section 12004). To notify the Bureau of the physical relocation of a gambling establishment, please use form Notice of
Relocation, CGCC-CH7-02 (Rev 01/21).
Please note: To change your name you must submit a Badge Replacement Request
All information must be typed or printed legibly in blue or black ink.
SECTION 1: INFORMATION
NAME
LICENSE/PERMIT NUMBER, IF APPLICABLE
REQUESTOR
Cardroom Business Licensee
Cardroom Endorsee Licensee
Key Employee Licensee
Commission Work Permitee
TPPPS Business Licensee
TPPPS Endorsee Licensee
TPPPS Supervisor Licensee
TPPPS Worker Licensee
Manufacturer or Distributor
Designated Agent
Other: ____________________
SECTION 2: CHANGE IN CONTACT INFORMATION
Check each appropriate box and fill out all information as applicable.
NEW RESIDENCE/PHYSICAL OFFICE ADDRESS (STREET, CITY, STATE, ZIP CODE)
NEW MAILING ADDRESS IF DIFFERENT THAN NEW OR CURRENT RESIDENCE (STREET, CITY, STATE, ZIP CODE)
NEW PRIMARY NUMBER:
NEW ALTERNATIVE PHONE NUMBER:
NEW FAX NUMBER:
NEW EMAIL ADDRESS:
SECTION 3: DECLARATION
I declare under penalty of perjury under the laws of the State of California that the information in this form is true, accurate, and complete, and that
this declaration is executed by me at
.
City and State
PRINTED NAME
SIGNATURE
DATE (MM/DD/YYYY)
This form must be signed by the appropriate person identified below:
 If applicant/licensee is a corporation, LLC, or joint venture then by an authorized officer.
 If applicant/licensee is a general partnership or limited partnership then by an authorized partner.
 If applicant/licensee is a sole proprietor then by the owner.
 If applicant/licensee is a trust then by an authorized trustor or trustee.
 If applicant/licensee is a natural person then by the applicant/licensee.