Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697627113832.pdf (Antigua and Barbuda)
TTTTHE HE HE HE DDDDIRECTORATE OF AMING FFSHORE GGGGAMING IRECTORATE OF OOOOFFSHORE AMING AMING FFSHORE FFSHORE IRECTORATE OF IRECTORATE OF APPLICATION FOR AN INTERACTIVE GAMING APPLICATION FOR AN INTERACTIVE GAMING APPLICATION FOR AN INTERACTIVE GAMING APPLICATION FOR AN INTERACTIVE GAMING OR INTERACTIVE WAGERING LICENCE OR INTERACTIVE WAGERING LICENCE OR INTERACTIVE WAGERING LICENCE OR INTERACTIVE WAGERING LICENCE Schedule “C”: Schedule “C”: Schedule “C”: Schedule “C”: PACKAGE” INFORMATION PACKAGE” PERSONAL INFORMATION ““““PERSONAL PACKAGE” PACKAGE” INFORMATION INFORMATION PERSONAL PERSONAL Schedule “C” The Directorate of Offshore Gaming – Antigua and Barbuda PERSONAL INFORMATION This is Schedule “C” to the regulations concerning Interactive Gaming and Interactive Wagering All information provided by the Applicant to the Directorate of Offshore Gaming will be held in the strictest confidence and will not be used by the Directorate for any purpose other than matters pertaining to this application, unless it is required for the administration or enforcement of the Regulations or if it is related to an official investigation.
THIS PERSONAL INFORMATION PACKAGE CONTAINS THE FOLLOWING DOCUMENTS.

PLEASE ENSURE YOUR PACKAGE IS COMPLETE 1.

2.

3.

4.

5.

Instructions for completion.

Oath or Solemn Affirmation.

Authority for release of information.

Personal Information Form.

Attachment page.

Application for Interactive Gaming or Wagering License 2 of 20 Schedule “C” The Directorate of Offshore Gaming – Antigua and Barbuda INSTRUCTIONS FOR COMPLETION 1.
This Personal Information package must be completed by each director, partner and chief executive officer of the applicant Business Entity, duly authorized key person, and shareholder with five (5%) percent or more ownership of or controlling interest in the applicant Business Entity.

2.

Type or print in BLOCK LETTERS an answer to every question.

3.

If a question does not apply, state “N/A” in response to that question.

4.
4.

If there is nothing to disclose in reply to a particular question, state “nil” in response to that question.

5.

If there is insufficient space on a printed form in which to answer a question, additional information may be provided on an attachment page, a form for which is attached.

6.

When required to use an attachment page, precede each answer thereon with the title applicable to that question.

7.

All dates should be completed in the form: Day/Month/Year.

8.
8.

This form is to be completed in the English language.

Any documents required to be provided are to have a certified English translation appended.

9.

Failure to give true and correct answers to any questions in this form will be grounds for the Directorate to refuse an application or revoke a licence that has been granted on the basis of untrue or incorrect information.

10.
10.

The completed form should be forwarded by registered mail or courier to: The Directorate of Offshore Gaming The First Caribbean Financial Centre Old Parham Road St. John’s Antigua 11.

The Personal Information package should be sealed in an envelope and marked “Private and Confidential”.

12.

Any further enquiries should be directed to the Directorate.
Application for Interactive Gaming or Wagering License 3 of 20 Schedule “C” The Directorate of Offshore Gaming – Antigua and Barbuda OATH OR SOLEMN AFFIRMATION BY THE APPLICANT BEFORE AN AUTHORIZED PERSON I, ________________________________________ OF ________________________________ SWEAR OF SOLEMNLY AFFIRM THAT: 1.

I am the_____________________________ of _________________________________ (Relationship of declarant to the applicant) (Name of applicant) 2.

3.
3.

I have personally completed (or I am personally responsible for providing the information contained in) the Business Entity Information Form to which this Declaration is appended.

I certify that the particulars contained in the Business Entity Information Forms are true and correct in every detail and fully disclose the information to complete the Business Entity Information Form.
________________________________________________ (Signature of applicant) ( ) Sworn before me, __________________________________________ ( ) Solemnly affirmed before me, ________________________________ at ___________________________________________ this __________________________________________ _____________________________________________ (Signature) _____________________________________________ (Given name and name in block letters) (Specify in which capacity this declaration is taken: as commissioner for oaths, justice of the peace, lawyer, notary, mayor, clerk or secretary-treasurer of a municipality, registrar or clerk of a court of competent jurisdiction) Application for Interactive Gaming or Wagering License 4 of 20 Schedule “C” The Directorate of Offshore Gaming – Antigua and Barbuda AUTHORITY FOR RELEASE OF INFORMATION I, ________________________________________ of _________________________________ (Full Name) (Address) grant an authority on the following terms: 1.
I authorize the Directorate of Offshore Gaming (the “Directorate”), and any person conducting any investigations or enquiries on behalf of the Directorate, to cause to be made investigations about me for the purposes of determining my suitability for the purposes of an Interactive Gaming or Interactive Wagering License under the Regulations concerning Interactive Gaming and Interactive Wagering (the “Regulations”) 2.
I authorize the Directorate and any person conducting any investigations or enquiries on behalf of the Directorate for the purpose of the Regulations (collectively referred to herein as the “Authorized Persons”), to obtain any information and make any investigations or enquiries which relate to me and may be relevant to any of the purposes of the Regulations, in any jurisdiction.

3.
3.

I authorize the manager or other principal officer of any branch or office of a bank or financial institution in any jurisdiction to whom a copy of this release is presented to allow any Authorized Person to inspect and obtain copies of, or to release to any authorized person, any record, document or other information of any kind in written, electronic or any other form, which relates to me and is held by the bank or financial institution.

4.
4.

I authorize any officer of any police service, law enforcement agency or regulatory body in any jurisdiction to whom a copy of this release is presented to release to any Authorized Person any information or official record of any kind in written, electronic or any other form, which relates to me and is held by the police service, agency or body, including any information relating to my personal and criminal history.

5.
5.

I will at all times sufficiently indemnify the Authorized Persons and keep the Authorized Persons indemnified against all liability in respect of the supply or publication of the information and against all actions, suits, proceedings, claims, demands, costs and expenses whatsoever which may be taken against the Authorized Persons or incurred or become payable by the Authorized Persons in respect thereof.

Signed at: _____________________ this __________ day of _____________, _____.
Signature: _____________________ Signature of Witness: _____________________ Print name of Witness: ______________________ Application for Interactive Gaming or Wagering License 5 of 20 Schedule “C” The Directorate of Offshore Gaming – Antigua and Barbuda PERSONAL INFORMATION FORM 1.

_________________________ ________________________ ___________________ Surname First Middle 2.
Alias (es), nicknames, maiden name, other name changes, legal or otherwise, you have used or by which you have been known: _____________________________________________ 3.

Present residential address (es): _________________________________________________ No.

& Street __________________________________________________________ City Province/State __________________________________________________________ Postal Zip Code Country 4.
Occupation: ________________________________________________________________________ Telephones: ___________________________________ Business: _____________________________________ Home: _______________________________________ Fax: ________________________________________ E-mail: _______________________________________ 5.
Date of birth: ________/ ________ /___________ Sex: _____________ (Day/Month/Year) Place of birth: __________________ ____________________ ____________________ City Province/State Country 6.

Social Insurance Number, Social Security Number or the equivalent for your jurisdiction: ___________________________________________________________________________ Application for Interactive Gaming or Wagering License 6 of 20 Schedule “C” The Directorate of Offshore Gaming – Antigua and Barbuda 7.
Physical description: Height: ____________ cms / ft.in.

Weight: ____________ kgs / lbs.

Colour of eyes: _________________ Colour of hair: _________________ Complexion: ___________________ Scars, tattoos or other distinguishing marks: ______________________________________ 8.

Are you enrolled in an Electoral Roll?

Yes 1 No 1 If yes, state the name and address under which enrolled: ____________________________ Electoral District, Division, Country: ___________________________________________ 9.
Are you the holder of a current Driver’s License?

Yes 1 No 1 If yes, please attach a certified copy of your driver’s license which should include date and place of issue: License No.

: ___________________________ (Note: You may be required to produce your Driver’s License if an interview is to be conducted) MARITIAL INFORMATION 10.

What is your marital status, including any common-law relationship?
(If applicable, complete the following): Date of Marriage: _______________/ ______________/ ____________________________ (Day/Month/Year) Palace Of Marriage: __________________ _______________________ _____________ (City) (Province/State) (Country) Full name of Spouse: _________________________________________________________ Maiden name of Spouse (where applicable): _________________________________________ Date of birth of Spouse: __________________ _________________ ___________________ (Day/Month/Year) Application for Interactive Gaming or Wagering License 7 of 20 Schedule “C” The Directorate of Offshore Gaming – Antigua and Barbuda Place of birth of Spouse: ______________________________________________________ 11.
Residential address of Spouse: __________________________________________________ ___________________________________________________ City Province/State No.

& Street ___________________________________________________ Postal Zip Code Country Spouse’s Employer: __________________________________________________________ Spouse’s Occupation: _________________________________________________________ 12.

List of current names (including maiden surname) and current addresses of previous spouses.
If Deceased, indicate accordingly.

(a) Current Name (in full): ____________________________________________________ Maiden Surname: _______________________________________________________ Current Address: _______________________________________________________ _______________________________________________________ City Province/State No.

& Street ________________________________________________________ Postal Zip Code Country FAMILY PARTICULARS (Note: Details of deceased persons are also required) 13.
Father: ____________________ ____________________ _ _______________________ Surname First Middle Date of Birth: ________________ / _______________ / _______________________ (Day/Month/Year) Application for Interactive Gaming or Wagering License 8 of 20 Schedule “C” The Directorate of Offshore Gaming – Antigua and Barbuda Occupation: ___________________________________________________________ 14.
Mother: ________________________ _____________________ ____________________ Surname First Middle Date of Birth: ____________________ /_____________________ /___________________ Day/Month/Year) Occupation: _________________________________________________________________ 15.

List all brothers and sisters.

Show relationship of each.

Relationship Full Name Address Occupation 16.

Children: List all, including steps or adopted children.

Show relation of each.


Relationship Full Name Address Occupation EDUCATION / QUALIFICATIONS 17.

What level of education did you attain?

__________________________________________ 18.

Name of last educational institution attended: _____________________________________ 19.
List any memberships in professional bodies (past and present): ______________________ Application for Interactive Gaming or Wagering License 9 of 20 Schedule “C” The Directorate of Offshore Gaming – Antigua and Barbuda MILITARY SERVICE 20.

Have you ever served in the military of any country?
Yes 1 No 1 If yes, complete the following Country: ___________________________________________________________________ Arm of Service: ______________________________________________________________ Branch and Unit Number: ______________________________________________________ Date of Entry: _________________/ _____________________/ ________________________ (Day/Month/Year) Date of Discharge: _____________/ _____________________/ ________________________ (Day/Month/Year) Type of Discharge: ____________________________________________________________ Rank at discharge: _____________________________________________________________ While in the armed forces were you ever arrested for an offence which resulted in summary action, a trial or court marital?
Yes 1 No 1 PASSPORT AND TRAVEL INFORMATION (if applicable) 21.

For each passport that you hold please attach a certified copy of your passport (if insufficient space use an attachment page).

Passport information should include: Passport Number: _______________________________ Country: ______________________________________ Place of issue: __________________________________ Date of issue: _______ / _______ / ________ (Day/Month/Year) Date of expiration: ______ / ______ / ______ Passport photograph: 22.
Have you ever traveled outside your country of residence for a period of time exceeding one (1) month during the past five (5) years?

Yes 1 No 1 Application for Interactive Gaming or Wagering License 10 of 20 Schedule “C” The Directorate of Offshore Gaming – Antigua and Barbuda ARRESTS, DETENTIONS AND LITIGATION 23 .Have you ever been charged, arrested or summoned for an offence, regardless of the disposition, in any jurisdiction excluding juvenile offences and traffic offences?
Yes 1 No 1 If yes, give detail in the space provided below.

List all cases without exception.

Nature of offence Age at time of offence City, Province/State, Country of offence Date of offence Result of Hearing or other disposition 24.

Have you ever been a party in a civil lawsuit in which an amount exceeding Ten Thousand ($10,000.00) dollars was claimed, or are you aware of any such action that may be pending?
Yes 1 No 1 If yes, please provide details on an attachment page including: • Name of parties • City, Province/State and Country in which action commenced • Level of Court • Date action commenced • Nature of action (give brief description) • Status of action • Disposition of action • If a judgement has been entered, has it been satisfied?

Give details 25.

Have you ever had a judgement entered against you?

Yes 1 No 1 If yes, please give details on an attachment page.

(Unless already provided).

26.


Has your salary, wage, earnings or other income been subject to a garnishee order, attachment or other judicial proceeding?

Yes 1 No 1 If yes, please give details on an attachment page.

Application for Interactive Gaming or Wagering License 11 of 20 Schedule “C” The Directorate of Offshore Gaming – Antigua and Barbuda 27.

Have you ever had an article repossessed by a finance company or other institution?

Yes 1 No 1 If yes, please give details on an attachment page.

28.
28.

If requested, will you provide addresses at which you have been permanently resident over the last ten (10) years beginning with your current address and working backwards, and show the time period at each residence?

____________________________________ EMPLOYMENT 29.

Beginning with your current employment and working backwards, list your work history on an attachment page.
Particulars to be provided are: • Duration of employment • Name, business address and telephone number of employer • • Reason for leaving • Name of person to whom you reported Job title and description of duties 30.

Have you ever been dismissed, discharged or asked to resign from any employment?

If yes, complete the following: No Yes / Date Name and address of employer Supervisor’s name Reason for dismissal, discharge or resignation 31.
Directorships and business affiliations: • On an attachment page, provide full details of any other directorships, partnerships or other business interests or affiliations with which you are currently associated or previously associated.
Yes 1 No1 • Are you or have you been associated with the ownership, administration or management of, or held any financial interest in: Interactive gambling or betting operation; • A casino; • Keno or lottery operations; • • Race wagering or wagering operations: • Club, hotel or tavern; • The manufacture, assembling, selling, distributing, importing, supplying or repairing of gaming machines on-line machines or other amusement devices; Yes 1 No 1 Application for Interactive Gaming or Wagering License 12 of 20 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 Yes 1 No 1 No 1 No 1 No 1 No 1 No 1 Schedule “C” The Directorate of Offshore Gaming – Antigua and Barbuda • Any other gaming or gambling operation If yes, please provide details on an attachment page.
32.

Other than as indicated above, please provide details on an attachment page if you have at any time been engaged in bookmaking or sports book operations in any capacity or otherwise involved in the racing industry.

33.

Have you ever been involved in any company that has been in liquidation or receivership or been placed under administration?

Yes 1 No 1 If yes, please provide details on an attachment page.
CHARACTER REFERENCES Nominate three (3) persons who are not related to you and who have known you for a period of not less than five (5) years.

Persons giving references may be contacted for additional information.

34.
Name: _____________________________________________________________________ Address: ___________________________________________________________________ Occupation: ________________________________________________________________ Telephone: _____________________________ Years known: __________________ Name: _____________________________________________________________________ Address: ___________________________________________________________________ Occupation: ________________________________________________________________ Telephone: _____________________________ Years known: ____________________ Name: _____________________________________________________________________ Address: ___________________________________________________________________ Occupation: ________________________________________________________________ Application for Interactive Gaming or Wagering License 13 of 20 Schedule “C” The Directorate of Offshore Gaming – Antigua and Barbuda Telephone: ______________________________Years known: __________________ FINANCIAL DETAILS 35.Have you ever become bankrupt or availed yourself of the laws relating to bankruptcy or insolvency?
Yes 1 No 1 If yes, please provide details on an attachment sheet.

36.

If requested to produce copies of your income Tax Returns, will you do so?

Yes 1 No 1 37.
STATEMENT OF ASSETS (You may be required to provide certified copies of your assets) As of the day of ____________________________________, (Date of this Statement or whatever date that is convenient in the last 12 months) Describe fully, if additional space is required use attachment pages: Cash in: __________________________ $ ____________________ _________________ Financial Institution Branch Account Number Cash in: __________________________ $ __________________ Financial Institution Branch _________________ Account Number Cash in: __________________________ $ _____________________ _________________ Account Number Financial Institution Branch Debts owing to you by other persons (give details and dates due): $ _________________ _____________________________________ _______ / _____ / _____ (Day/Month/Year) $ _________________ _____________________________________ _______ / _____ / _____ (Day/Month/Year) $ _________________ _____________________________________ _______ / _____ / _____ Day/Month/Year) Other current assets (give details) Application for Interactive Gaming or Wagering License 14 of 20 Schedule “C” The Directorate of Offshore Gaming – Antigua and Barbuda _________________________________________________________ $ ___________________ ________________________________________________________ $ ___________________ Investments: Shares, bonds, mutual funds, debentures, notes, etc.
Company Type No.
Held Year of Acquisition Total Estimated Acquisition Cost Market Value Investments, other than those listed above: Description _________________________________________ Total Acquisition Cost ________________________ Estimated Market Value __________________ Fixed Assets: ______________________________________________________________________ Real estate (own residence and other properties): Location and description ________________________________________ Year of ______________ Acquisition ___________________________________ Estimated Market Value _________________ Acquisition ___________________________________ Price ________________________________ Application for Interactive Gaming or Wagering License 15 of 20 Schedule “C” The Directorate of Offshore Gaming – Antigua and Barbuda Other Assets (over $5,000 per item): (Motor vehicles, airplanes, recreation vehicles, boat, furniture, jewelry, etc.)
Description Acquisition cost Market value TOTAL ASSETS: $ _______________________________ 38.

STATEMENT OF LIABILITIES As of the _____________ day of __________________________________, ________________ (Date of this Statement or whatever date that is convenient in the last 12 months) Describe fully.

Indicate secured and unsecured liabilities.

If additional space is required, use attachment pages.

Long Term liabilities (including mortgages) Loan value: $ ________________________ Loans etc.
$ _________________________ ___________________________________________ Borrower’s name _________________________________________________ __________________________ Financial Institution Branch Due date _______ / ______ / _______ Monthly repayment: _______________________________ (Day/Month/Year) Loans etc.
$ _______________________ _________________________________________ Borrower’s name __________________________ ___ Financial Institution __________________________________________ Branch Due date ______ / ______ / ________ Monthly repayment: _________________________ Application for Interactive Gaming or Wagering License 16 of 20 Schedule “C” The Directorate of Offshore Gaming – Antigua and Barbuda Other long-term liabilities: Name Address Lender / Creditor Repayment Details Current liabilities (indicate name and address of creditor) _______________________________________________ $ ____________________________ _______________________________________________ $ ____________________________ Other liabilities (Include Contingent liabilities i.e.
Liabilities of an indefinite nature or unspecified amount for which you may become liable in the future) _______________________________________________ $ ____________________________ _______________________________________________ $ ____________________________ TOTAL LIABILITIES $ ____________________________ NET WORTH (Total Assets-Total Liabilities) $ ____________________________ 39.
SOURCE OF FUNDS Indicate hereunder the sources over the past five (5) years of all income and other benefits received for your use of disposal (whether received in money or in kind) whether as a result of your employment or association with any corporation, partnership, trust, joint venture or business or otherwise.

List the amount and source of each item received by yourself (and your spouse / common law spouse, if received jointly) and list each year separately.
Application for Interactive Gaming or Wagering License 17 of 20 Schedule “C” The Directorate of Offshore Gaming – Antigua and Barbuda Year ended: Source Amount TOTAL $_______________________ Year ended: _______________________________ Source Amount TOTAL $_______________________ Year ended: _______________________________ Source Amount TOTAL $_______________________ Year ended: _______________________________ Application for Interactive Gaming or Wagering License 18 of 20 Schedule “C” The Directorate of Offshore Gaming – Antigua and Barbuda ATTACHMENT PAGE – Schedule C Question Number: Signature: _______________________________________ Application for Interactive Gaming or Wagering License 19 of 20 Schedule “C” The Directorate of Offshore Gaming – Antigua and Barbuda DECLARATION By signing below, I declare that: 1.
The information contained in this application is complete and accurate; 2.

In the case of a corporation, partnership or other business entity, that I am duly authorized to make the application on behalf of the corporation, partnership or other business entity named as applicant; 3.

I have been provided with a copy of the Interactive Gaming and Interactive Wagering Regulations.
The applicant agrees to abide by the provisions of the Regulations which will be the law governing the applicant’s relationship with the Directorate of Offshore Gaming of Antigua and Barbuda.

Signature: _____________________________________ Name: ________________________________________ (Please Print) Date: _________________________________________ End of Schedule “C”.

Please go on to Schedule “D”.

Application for Interactive Gaming or Wagering License 20 of 20