Attachment_13_Vendor_Personal_Disclosure_Form_Final.pdf

Personal Disclosure Form

Oregon State Lottery

Name Business Name

Investigations Conducted By Oregon State Police Revised November 2025 Gaming Enforcement Division Confidential

Hand-print or type an answer to every question. If a question does not apply to you, state N/A. If space available is insufficient, continue on a separate sheet and precede each answer with the appropriate title (and number).

Do not misstate or omit any material fact(s) as each statement made herein is subject to verification. Applicant must initial each page as provided in lower, right-hand corner. By placing his/her initials on each page, the applicant is attesting to the accuracy and completeness of the information contained on that page.

PLEASE ENCLOSE THREE (3) FINGERPRINT CARDS OF APPLICANT.

All applicants are advised that this personal history record is an official document and misrepresentation or failure to reveal information requested may be deemed to be sufficient cause for the refusal or revocation of a contract or agreement.

The applicant is hereby advised that he/she is seeking the granting of a contract and that the burden of proving qualification for a favorable determination is at all times on the applicant. In compliance with Public Law 93-579 7 (5 USC 552(a)), you are hereby notified that the disclosure of your social security number is voluntary. It will be used to obtain a credit history and to check criminal history records. Your refusal to provide your social security number for this purpose will delay processing of your application.

Applicant’s Initial_____

AFFIX A PHOTOGRAPH OF APPLICANT HERE

THAT WAS TAKEN WITHIN THE PAST YEAR

PERSONAL DISCLOSURE

GENERAL INSTRUCTIONS

1. APPLICANT

Last Name

First Name Middle Name

Aliases (nicknames, maiden name, other name changes, legal or otherwise)

Residence Address

City/State/Zip

Employer/Address

Occupation/Title

Work Phone Home Phone Cell Phone

Birth Date

Place of Birth (City, County, State, Country)

Height

Weight Sex Color of Hair Color of Eyes

Complexion

Social Security Number

Driver’s License Number State

Of what country are you a citizen? _____________________________

2. MARITAL INFORMATION

What is your current marital status?

Single □ Married □ Separated □ Divorced □ Widowed □ Engaged □

Current Marriage:_________________________________________________________________________ Date Place (City, County, State)

Spouse’s Full Name

Maiden Name

Residence Address

Employer/Address

Occupation/Title Work Phone Home Phone

Social Security Number

Birth Date

Place of Birth

Previous Marriages:

List the names and current addresses of previous spouses:

Name Birth Date Address (street, city, state, zip) Telephone #

Applicant’s Initial_____

PERSONAL INFORMATION

SECTION 1

3. FAMILY INFORMATION

Children and Dependents: List all children, including stepchildren and adopted children and give the following information:

Name Birth Date Residence Address (street, city, state, zip)

Parents: List names, residence addresses, dates of birth, and most recent occupations of parents, parents-in-law, or legal guardian. Indicate if retired or deceased and list last address and occupation.

Name (Maiden) Birth Date Address (street, city, state, zip) Occupation

Father: __________________________________________________________________________________

Mother: __________________________________________________________________________________

Father-in-Law:_____________________________________________________________________________

Mother-in-Law: ____________________________________________________________________________

Brothers and Sisters/Step-Brothers and Step-Sisters: List names, residence addresses, dates of birth, and most recent occupations of brothers and sisters and step-brothers and step-sisters.

Full Name (Maiden) Birth Date Address (street, city, state, zip) Occupation

4. EDUCATION

Name of School Location Dates Attended Diploma/Degree Earned

High School

College/University College/University Other

5. MILITARY INFORMATION

Have you ever served in a military organization or been a member of a reserve force of any country?

□ Yes □ No

If yes, attach a copy of your military records (DD214 for US Services).

Country of Service:______________________________ Branch:____________________________________

Date of entry—active service:______________________ Date of separation:___________________________

Type of discharge:_______________________________ Rank at separation: __________________________

Serial Number: _________________________________

Have you ever been tried by military court martial or have you had charges filed against you under a Code of Military Justice? □ Yes □ No

If yes, furnish details on a separate page including nature of charge or arrest, date, location, name of military organization filing charges, disposition, and sentence.

6. RESIDENCES

List all residences you have had for the last 10 years.

Month and Year (From—To) Street and Number City State/Zip

7. EMPLOYMENT AND BUSINESS ASSOCIATIONS

Beginning with your current employment, list your work history, all businesses with which you have been involved, and/or all periods of unemployment for the past 10 years. Also list all corporations, partnerships or any other business ventures with which you have been associated as an officer, director, owner, or related capacity. Mark “yes” under “Gaming Present” if gaming devices, including lottery tickets, were on the premises or if any form of gambling took place on the premises during the period of your employment.

Month and Year (From-To)

Name/Mailing Address of Employer/Business

Title

Description of Duties Gaming Present: □ Yes □ No Type:

Supervisor’s Name

Monthly Salary or Hourly Wage Reason for Leaving

If additional space is needed, continue on separate sheet.

Regarding the previously listed employment and business associations:

a. Were you ever discharged, suspended, or asked to resign from employment? □ Yes □ No

b. Within the last ten years, have you been charged with any infraction in relation to any employment which was the subject of any disciplinary action? □ Yes □ No

If yes to either question, provide details on a separate sheet as to each incident.

8. CHARACTER REFERENCES

Provide five character references, over the age of eighteen, who have known you for five years or more. Do not include relatives, present employer, or employees.

Name Home Address

Employer Work Address

Home Phone Work Phone Cell Phone Years Known

1. Have you ever been convicted at any time of any crime? □ Yes □ No

Do you have any Class “A” misdemeanor or felony charges pending against you? □ Yes □ No

2. Have you ever been convicted of violating any of the gambling laws of any state, country or local municipality? □ Yes □ No

3. Have you ever engaged in any type of unlawful gambling or gaming? □ Yes □ No

If yes, explain ______________________________________________________________________

LEGAL PROCEEDINGS

SECTION 2

4. Have you been convicted of a crime and…

a. Had the conviction “purged” from your record? □ Yes □ No

b. Been given a “deferred sentence”? □ Yes □ No

c. Been given a “diversion”? □ Yes □ No

(If you answered yes to questions 1 or 2, please provide details in the space below. List all cases without exception, in any state, province, or jurisdiction.)

Date Age Charge Location (City, State) Conviction Description

To obtain a copy of your Identity History Summary check, also referred as “Criminal History Record”, visit:

https://www.fbi.gov/services/cjis/identity-history-summary-checks

To obtain more information on the Oregon State Police Criminal History check visit:

https://www.oregon.gov/osp/programs/cjis/Pages/CCH.aspx

8. Have you as an individual, member of a partnership, or owner, director, or officer of a corporation, ever been a party to a lawsuit as either a plaintiff or defendant? (other than divorces) □ Yes □ No

If yes, list all cases without exception in any state, jurisdiction, or county.

Plaintiff/Defendant Court Case Number City, County, and State Disposition

9. Have you as an individual, member of a partnership, or owner, director, or officer of a corporation, ever been a defendant in any civil lawsuit which was predicated in whole or in part upon conduct which allegedly constituted a crime or crimes? □ Yes □ No

If yes, furnish details on a separate page.

10. Have you as an individual, member of a partnership, owner, director, or officer of a corporation ever been a party to a bankruptcy filing? □ Yes □ No

11. Is there a tax lien on your income or assets? □ Yes □ No

If yes, furnish details on a separate page.

12. Have you ever held a privileged or professional license in any state, including but not limited to the following? □ Yes □ No

Liquor Boxing Promoter Real Estate Broker or Salesman Race Horse/Race Dog Owner

Accountant Jockey Lawyer Trainer or Manager Doctor Securities Dealer

Gaming or Gambling Alcohol Serving Permit

If yes, list type of license, where, years held, and the nature of any disciplinary actions taken against you.

13. Have you ever held a financial interest in a race track, dog track, race horse or race dog, lottery, casino, bookmaking operation or pari-mutuel operation? □ Yes □ No

If yes, list when and where and give names and locations of the businesses in which you were involved and the names and addresses of all partners.

14. Have you ever owned, maintained, or operated any gaming operation? □ Yes □ No

If yes, list when and where and give names and locations of the businesses in which you were involved and the names and addressed of all partners. (Provide complete information on a separate sheet.

Include a detailed description of any owners, ownership percentages, and locations or contracts held in any gaming operation.)

For questions 15-29, if the answer to any question is “Yes”, provide complete details on a separate sheet and refer to the question by number.

15. Have you ever appeared before any licensing agency or similar authority in or outside the State of Oregon for any reason whatsoever? □ Yes □ No

16. Have you ever applied for, sought renewal of, received, been denied, have pending, or ever had revoked a gaming license of any kind in any state or jurisdiction? □ Yes □ No

17. Do you conduct any business in any state(s) or jurisdiction(s) including Oregon? (If “Yes, indicate nature of the business, its name and address for each state or jurisdiction.) □ Yes □ No

18. Do you have any contracts in any state or jurisdiction to supply gaming goods or services including but not limited to lottery goods and services? (If “Yes”, indicate the nature of goods and services involved for each state or jurisdiction.) □ Yes □ No

19. Have you ever held any federal, state, or local elective position? □ Yes □ No

20. Have you, within the past five years, contributed to any local, state, or federal political candidate or committee in this state where such contributions were reportable under any existing state or federal law?

□ Yes □ No

21. Do you have a joint venture or other contractual agreement with any entity to supply any private businesses, Indian Tribes, state or jurisdiction with gaming goods or services? □ Yes □ No

22. Have you ever been the subject of any order, judgment, or decree of any court of competent jurisdiction permanently or temporarily enjoining your right to engage in any type of professional or business practice or activity? □ Yes □ No

23. Do you know of any economic interest held in your business by any person employed by or who is an official of the State of Oregon? □ Yes □ No

24. Do you have any relatives associated with or employed in the gaming, liquor, coin or token-operated gambling device industry? □ Yes □ No

25. Do you have any personal or business relationship with an Oregon Lottery employee or official?

□ Yes □ No

26. Do you have a financial interest or ownership in any known Oregon Lottery vendor or contractor?

□ Yes □ No

27. To the best of your knowledge, have you ever been employed by or associated with any business or person connected in any way with an illegal gambling or gaming enterprise? □ Yes □ No

28. Have you engaged in any type of unlawful gambling or gaming? □ Yes □ No

29. Have you ever served as a Lobbyist for any corporation or business? □ Yes □ No

If yes, provide details on a separate page, along with a copy of your Lobbyist registration form.

1. Describe your involvement in the management and/or operation of the business.

SECTION 3

RESPONSIBILITIES AND FINANCIAL INFORMATION

2. What are your responsibilities relating to the products or services the business will provide to the Oregon Lottery?

3. Have you provided any loans, investment capital, monetary advances, or other extensions of credit to the applicant? □ Yes □ No

If yes, provide the amount, source, and attach a copy of any written agreement or a written summary of any verbal agreement. If additional space is needed, provide this information on a separate sheet of paper.

4. Has your ownership interest in the applicant been assigned or pledged as security to any person, creditor, or lending institution? □ Yes □ No

If yes, provide name of person, creditor, or lending institution and nature of agreement in the space provided and attach a copy of the written agreement or written summary of any verbal agreement. If additional space is needed, provide this information on a separate sheet of paper.

5. Have you ever been involved in any bankruptcy proceeding in any jurisdiction (other than as a creditor)?

□ Yes □ No

If Yes, indicate the state or other judicial jurisdiction (district), date of filing of bankruptcy petition, type of bankruptcy proceeding, suit number, and disposition of suit. If additional space is needed, provide this information on a separate sheet of paper.

6. Have your IncomeTax Returns ever been audited? □ Yes □ No

If yes, provide year(s) in the space provided.

7. Have you ever been delinquent on any Federal, State, Parish/County or other jurisdictional Income Taxes owed? □ Yes □ No

If yes, indicate year(s), amount delinquent, and current disposition in the space provided.

FINANCIAL RECORDS DISCLOSURE AUTHORIZATION

TO ANY FINANCIAL INSTITUTION:

I authorize and direct you to disclose any and all records and to deliver true copies thereof concerning or pertaining in any way to me or to the undersigned business to any law enforcement officer of the Oregon State Police, Gaming Enforcement Division. Disclosure is authorized for any civil, administrative, or criminal action which may be undertaken by the State of Oregon against me or any other person or business. Further, I authorize and direct you to honor a true copy of the original of this authorization as if the copy were the original itself.

NOTICE TO APPLICANT:

I understand that pursuant to ORS 192.593(2)(d), I may revoke this authorization at any time in writing. Any such revocation shall be sent to the Oregon State Lottery, Assistant Director for Security, 500 Airport Road, SE, Salem, Oregon 97301, certified mail, return receipt requested.

EXCUTED this _______ day of ___________________, 20___.

Applicant’s Signature

Print Name

Applicant’s Title

AUTHORITY TO RELEASE CREDIT,

CHARACTER, AND VENDOR HISTORY INFORMATION

Having made application through the Oregon State Lottery, I hereby authorize a complete investigation of my record including personal history, academic record, job performance, credit record, civil litigation, banking records, corporate filings, and criminal arrest and conviction by the Oregon State Police, or another police agency authorized to conduct investigations, to ascertain any and all information which may concern personal credit, character, or history, whether same is of record or not, release your organization and all persons whomsoever from any charge because of furnishing said information. I authorize a true copy of the original of this authorization as if the copy were the original itself.

NOTICE TO APPLICANT:

I understand that pursuant to ORS 192.593(2)(d), I may revoke this authorization at any time in writing. Any such revocation shall be sent to the Oregon State Lottery, Assistant Director for Security, 500 Airport Road, SE, Salem, OR 97301, by certified mail, return receipt requested.

That I hereby attest that the information provided is true, accurate, and complete to the best of my knowledge.

Corporate Name (Please Print)

Name

Signature Date

Telephone

SWORN STATEMENT AND DEPOSITION

State of________________) ) ss.

County of_______________)

I, __________________________________, being duly sworn, depose and say that I have read the above and attached statements, documents, information, and organizational chart, and that they are true and correct to the best of my knowledge and belief. Further, this statement is executed with the knowledge that misrepresentation or failure to disclose made in the above disclosure may be deemed sufficient cause for the refusal by the Oregon State Police, Gaming Enforcement Division. Further, that I am aware that later discovery of an omission or misrepresentation made in the above statements, documents, information, and organizational chart may be grounds for the cancellation of an existing contract or agreement. Further, that I am voluntarily submitting this disclosure under oath with the full knowledge that Oregon Revised Statute 162.075, False Swearing, provides that, “(1) A person commits the crime of false swearing if the person makes a false sworn statement, knowing it to be false, and (2) False Swearing is a Class A Misdemeanor.”

Signature Printed Name Title

I,________________________________, do hereby certify that I have prepared this document on Representative’s Name behalf of the vendor/company/applicant. That I hereby attest that the information provided is true, accurate, and complete to the best of my knowledge.

Signature Printed Name Title Business Address: _______________________________________ Telephone Number: _______________________

ADDITIONAL INFORMATION

(Add additional sheets as necessary)