**Tribe Name**

Determination of Eligibility/Suitability & Notification of Results to NIGC

**(25 USC 2710(b)(2)(F) & 25 CFR - 556.6(b)(2))**

I. **APPLICANT INFORMATION:**

Employee Name_______________________________________	SSN_________________	DOB________________

**Applicant Status**: □ Key Employee	□ Primary Management Official	Job Title or Position________________

Date on which applicant began or will begin work as key employee or primary management official	________________

II. **A SUMMARY OF THE INFORMATION PRESENTED IN THE INVESTIGATIVE REPORT:**

· Current Address & Residence History (previous 5 years)	□ Credit Check

· Past Employment	□ Proof of Self-employment

· Personal Character References	□ Tribal and/or District Court Record Check

· Criminal History 	□ Verified existing and previous relationships with 	Indian Tribes and the gaming industry.

· Every known criminal charge brought against the applicant within the last 10 years of the date of application:

________________________________________________________________________________________________

________________________________________________________________________________________________

· Every felony of which the applicant has been convicted or any ongoing prosecution.

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

**OTHER GAMING LICENSES VERIFIED:**

· Gaming licenses previously denied: ______________________________________________

· Gaming licenses revoked, even if subsequently reinstated_____________________________

· Employee has never applied for another gaming license

· Employee has applied for previous gaming license 

· Licensing agency: __________________License Status & Position: ____________________

· Licensing agency: __________________License Status & Position: ____________________

III. **ELIGIBILITY DETERMINATION:**

Based upon the information reviewed and the investigative findings and taking into consideration the applicant’s prior activities, criminal record, if any, reputation, habits and associations, the Gaming

Commission has determined that the above-named individual:

· Is eligible for a gaming license.

· Is not eligible for a gaming license.

· Should be **granted**a gaming license.

· Should be granted a **conditional**gaming license for a period of 	months.

· Condition____________________________

· Should be **denied**a gaming license.

· □ Did not fully and correctly fill out their Tribal License application as required.

· □ Other________________________________________

· Has had their license **revoked**for cause. 

· Revoked for (optional)__________________________

· Not licensed by the Tribe.

Notes related to the above determination (if needed): ____________________________________________________

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_________________________________________________________	_______________________________________

Authorized Tribal Official	Date

**Black: Requirement per regulation for NOR submission**

**Red: Not required but may be included on NOR submission**

**Blue: Required by NIGC-Tribe 2021 CHRI MOU**