EVT0009616-Vendor_Employee_Background_Information_Form.pdf

Vendor Employee Background Information

Read the complete form before filling it out. This form must be completely filled out: typed or printed legibly in ink. In the event the space provided for information is insufficient, attach additional sheets. Please include a copy of your current Driver’s License when you return this to the Lottery.

Review the attached information regarding obtaining fingerprinting. Your fingerprints can be obtained at most law enforcement agencies including the Kansas Bureau of Investigation.

All applicants should be aware that prior to appointment, Kansas Statute requires an extensive and detailed background investigation be conducted by the Kansas Lottery Security Division or Agents of the Kansas Bureau of Investigation or the Kansas Highway Patrol.

Return completed form to: The Kansas Lottery

Security Division 128 N. Kansas Avenue Topeka, Kansas 66603

Vendor Name and Address:

Rev 2015

PERSONAL INFORMATION

Full Name (First, Middle, Last) Social Security Number

Date of Birth (mm/dd/yyyy) Place of Birth

Business Telephone# Residence Telephone# Cell Phone # Email Address

Drivers License Number & State of Issuance Have you ever held a drivers license in another state(s)? If so, please provide details:

List any other names you are known by or have been known by, and dates used:

RESIDENCE

List all present and previous addresses, both temporary and permanent. If exact address cannot be remembered, provide city and state.

Present:

Address/City/State/Zip From To Own ____ Rent ____

(If applicable) Landlord Name and Address/City/State/Zip Telephone Number

Previous:

Address/City/StateZip From To Own ____ Rent ____

Telephone Number (If applicable) Landlord Name and Address/City/State/Zip Previous:

Address/City/State/Zip From To Own ____ Rent ____

(If applicable) Landlord Name and Address/City/State/Zip Telephone Number

EDUCATION

List your post-high school educational experience in reverse chronological order. Please include any trade, technical, or extended professional training:

Institution: Dates Attended:

Institution Address:

Program of study or degree received:

Institution: Dates Attended:

Institution Address:

Program of study or degree received:

Institution: Dates Attended:

Institution Address:

Program of study or degree received:

EMPLOYMENT

List all present and previous employment information in reverse chronological order. If necessary, include additional pages. Please provide as many details as possible, and include any service as an officer or director of any company, corporation, or organization, regardless of whether compensation was received as a result of those duties.

Present Employer:

Company Name Address/City/State/Zip Telephone Number

Position/Title Employment Dates From To

Previous Employer:

Company Name Address/City/State/Zip Telephone Number

Position/Title Employment Dates From To

Previous Employer:

Company Name Address/City/State/Zip Telephone Number

Position/Title Employment Dates From To

Previous Employer:

Company Name Address/City/State/Zip Telephone Number

Position/Title Employment Dates From To

GENERAL

Have you ever been dismissed or asked to resign from any employment position? If yes, please explain.

Has any employer ever taken disciplinary action against you such as a demotion, suspension or a letter of reprimand? ____________ If yes, briefly explain:

List any state or jurisdiction where you hold or have held a gaming license, or were subject to a background investigation for the purpose of determining suitability to provide products or services in the gaming industry:

Have you ever had a professional license, security clearance, or certificate which was suspended, revoked or denied? If yes, please explain:

List all business or professional organizations to which you belong or have belonged in the past five years:

Organization Date

Organization Date

CRIMINAL HISTORY

Do you have any criminal charges pending in any jurisdiction? If yes, please explain:

Are you currently on parole or probation? If yes, explain. (Include dates, location, original charges, court, and supervising officer):

Have you or any company you have been associated with been the subject of any criminal investigation or inquiry? If yes, please explain:

List all criminal offenses for which you have been convicted. Include DUI’s, serious or habitual traffic offenses and nolo contendere pleas.

Charge Date of offense or charge City and State Court Final Disposition

Charge Date of offense or charge City and State Court Final Disposition

Charge Date of offense or charge City and State Court Final Disposition

CIVIL COURT ACTION

List all occasions within the last three years, in which you have been a participant (plaintiff, defendant, witness) in a civil court action. Please include divorce and small claims proceedings.

Nature of case:

Date of case: City, State & Court:

Disposition of case:

Nature of case

Date of case: City, State & Court:

Disposition of case:

FINANCIAL INFORMATION

List all current sources of income. Include approximate annual income totals:

Are you currently more than 60 days delinquent on any debt or obligation?___________________

If yes, list each creditor and amount delinquent_________________________________________

Do you currently owe any back income, property, sales, or any other taxes?__________________

If yes, explain___________________________________________________________________

Are there currently any outstanding judgments or liens against you or your spouse?____________

If yes, explain ___________________________________________________________________

GAMBLING

Have you ever been arrested for illegal gambling activities? If yes, please explain:

Do you currently owe any debt as a result of gambling? If yes, please explain:

Do you have any business and/or financial interest(s) with any organization involved in gaming or the lottery? If yes, please explain:

Have you, either individually or as a member of any group, ever been denied or withdrawn a gaming license or gaming license application? If yes, please provide details:

If Necessary, Include Additional Information On Separate Sheet And Attach. Rev. 10/12

KANSAS LOTTERY SECURITY DIVISION

Under penalty of perjury, I certify the answers and information provided on this background information form are true, complete, and correct.

Signature & Date

Subscribed and sworn to before me this ______ day of _______________________, 20____.

Notary

My commission expires __________________

Authorization To Obtain Consumer Credit Report

I authorize the disclosure of any information or records concerning my credit for employment or contract purposes with the Kansas Lottery, to any member of the Kansas Lottery Security Division or its designee.

Signature

Subscribed and sworn to before me this ______day of _____________________, 20____.

Notary Public Signature

My commission expires

RELEASE OF ALL CLAIMS

The undersigned has provided, will be providing, or has authorized other parties to provide to the Kansas Lottery or its designee information and documents in furtherance of a background and security investigation performed pursuant to the Kansas Lottery Act regarding the business entity or individual named below. In consideration thereof, on behalf of the named business entity and its successors and assigns, or on behalf of the named individual and his or her heirs, executors, and assigns, the undersigned hereby does release, remise, and forever discharge the State of Kansas, the Kansas Lottery, any designee of the Kansas Lottery, the Kansas Lottery Commission, and their respective members, agents, and employees, from any and all manner of actions, causes of action, suits, debts, judgments, executions, claims and demands whatsoever, known or unknown, in law or equity, which said business entity ever had, now has, may have, or claim to have against any of said parties arising out of or by reason of the processing or investigation of, or other action relating to, said background and security investigation.

(Signature of authorized person)

(Printed name and title)

(Printed name of business entity if applicable)

State of County of , SUBSCRIBED and SWORN to before me this _________ day of __________________, 20___.

Notary Public

My commission expires

AUTHORIZATION AND REQUEST TO RELEASE INFORMATION

Vendor or Applicant’s Full Name:

1. The above-named Vendor or Applicant, as is applicable (for ease of reference hereinafter referred to as

“Applicant”), hereby authorizes and requests all persons or entities to whom or which this request is presented having information relating to or concerning Applicant to furnish such information to a duly appointed agent of the Kansas Lottery or designee of the Kansas Lottery, whether or not such information would otherwise be protected from disclosure by any constitutional, statutory or other legal privilege.

2 Applicant hereby authorizes and requests all persons or entities to whom or which this request is presented having documents relating to or concerning Applicant to permit a duly appointed agent of the Kansas Lottery or designee of the Kansas Lottery to review and copy any such documents.

3. If the person or entity to whom this request is presented is a brokerage firm, bank, savings and loan, or other financial institution or an office of same, Applicant hereby authorizes and requests that a duly appointed agent of the Kansas Lottery or designee of the Kansas Lottery be permitted to review and obtain copies of any and all documents, records or correspondence pertaining to Applicant, including but not limited to past loan information, notes co-signed by Applicant, checking account records, savings deposit records, safe deposit box records, passbook records, and general ledger folio sheets.

4. Applicant hereby makes, constitutes, and appoints any duly appointed agent of the Kansas Lottery or designee of the Kansas Lottery Applicant’s true and lawful attorney in fact for Applicant in Applicant’s name, place, stead, and on Applicant’s behalf and for Applicant’s use and benefit:

(a) to request, review, copy, sign for, or otherwise act for investigative purposes with respect to documents and information in the possession of the person or entity to whom this request is presented as Applicant might;

(b) to name the person or entity to whom this request is presented and insert that person’s or entity’s name in the appropriate location on this request;

(c) to place the name of the Kansas Lottery agent or the Kansas Lottery’s designee presenting this request in the appropriate location on this request.

5. A reproduction of this request by photocopy shall be for all intents and purposes as valid as the original.

IN WITNESS WHEREOF, in my personal capacity as Applicant or on behalf of the above-named Vendor for which Vendor I am duly so authorized, I have executed this document at

City: State: ______________ on this day of , 20 .

By:

(Signature)

(Printed name and title if applicable)

SUBSCRIBED and SWORN to before me this _______ day of _________________, 20____.

Notary Public

My Commission expires: _____________

Kansas Law (KS 74-8719) prohibits the purchase of lottery tickets for the following:

“It is unlawful for any person to purchase a lottery ticket or share, or to share in the lottery winnings of a person, knowing that such person is:

(1) The executive director, a member of the commission or an employee of the Kansas lottery;

(2) an officer or employee of a vendor contracting with the Kansas lottery to supply gaming equipment or tickets to the Kansas lottery for use in the operation of any lottery conducted pursuant to this act;

(3) a spouse, child, stepchild, brother, stepbrother, sister, stepsister, parent or stepparent of a person described by subsection (a)(1) or (2); or

(4) a person who resides in the same household as any person described by subsection (a)(1) or (2).

(b) (1) Violation of subsection (a) is a class A nonperson misdemeanor upon conviction for a first offense.

(2) Violation of subsection (a) is a severity level 9, nonperson felony upon conviction for a second or subsequent offense.

I have read the above and understand the information contained therein.

Signature of applicant

Date: ________________

WAIVER AGREEMENT AND STATEMENT

Fingerprint-Based Record Checks for Noncriminal Justice Purposes

I hereby authorize The Kansas Lottery to submit a set of my fingerprints to the Kansas Bureau of Investigation (KBI) for the purpose of identifying me and accessing and reviewing Kansas and/or national criminal history records that may pertain to

me. Pursuant to K.S.A. 22-4701 et seq. and K.S.A. 22-5001, The Kansas Lottery may obtain my criminal history record information for noncriminal justice purposes. By signing this waiver, it is my intent to authorize release to The Kansas

Lottery any Kansas and/or national criminal history record that may pertain to me. I further understand that, if applicable, The Kansas Lottery may choose to deny me unsupervised access to children, the elderly, or individuals with disabilities until the criminal history background check is completed.

I understand that, upon my request, the The Kansas Lottery will provide me a copy of the criminal history background report, if any, received on me, and that I am entitled to challenge the accuracy and completeness of any information contained in any such report. I may be afforded a reasonable amount of time to correct or complete the criminal history record (or decline to do so) before The Kansas Lottery makes a final decision about my status as an employee, volunteer or contractor, or my eligibility for any pertinent license, certification or registration, or adoption. See 28 CFR 50.12(b).

I understand that officials receiving the results of the criminal history record check are to use those results only for authorized purposes and are prohibited from retaining or disseminating such results in violation of federal statute, regulation or executive order, or rule, procedure or standard established by the National Crime Prevention and Privacy Compact

Council. (See 5 United States Code (USC) 552a(b); 28 USC 534(b); 42 USC 14616, Article IV(c); 28 CFR 20.21(c), 20.33(d), and 906.2(d).)

I have ____ OR have not ____ been convicted of a crime.

If convicted, describe the crime(s), the date and location of the crime(s), and the name of the convicting court:

Under penalty of perjury, I hereby declare that I am the person described below, and understand that any falsification of this statement constitutes a severity level 9, nonperson felony under the provisions of Title 21 Kansas Statutes Annotated, Section 3805.

Signature Date

Printed Name Date of Birth

Residential Address City State Zip

WAIVER AGREEMENT AND STATEMENT (Cont.)

Fingerprint-Based Record Checks for Noncriminal Justice Purposes

RIGHT TO OBTAIN AND CHALLENGE ACCURACY

OF CRIMINAL HISTORY RECORDS

To obtain a copy of your Kansas criminal history record information (CHRI) to review for accuracy and completeness, you must send a set of your fingerprints, a letter requesting your record and payment of the appropriate fee to the KBI. For further details, including the current fee, visit the following Internet website: http://www.kansas.gov/kbi/criminalhistory.

Or, to provide official court documents to make a correction you may write to:

Kansas Bureau of Investigation Attn: Criminal History Records 1631 SW Topeka Blvd Topeka, Kansas 66612-1837

If a change is made to your Kansas criminal history record due to a challenge, a new copy of your Kansas criminal history record will be sent to the Authorized Recipient to make a final decision about your status as an employee, volunteer or contractor, or your eligibility for any pertinent license, certification or registration, or adoption.

To obtain a copy of your federal CHRI for review and challenge you must submit a set of your fingerprints and the appropriate fee to the FBI. Information regarding this process may be obtained at: http://www.fbi.gov/about-us/cjis/background-checks/background_checks. Or, you may write to:

FBI CJIS Division – Record Request

1000 Custer Hollow Road Clarksburg, West Virginia 26306

The FBI will forward your challenge to the appropriate contributing agency to verify or correct the entry. Upon receipt of an official communication directly from that agency, the FBI will make any necessary changes/corrections to your record in accordance with the information supplied by that agency (see 28 CFR 16.30 through 16.34). The Authorized Recipient must submit a new set of fingerprints and fee to receive the updated federal criminal history record.

ORIGINAL – MUST BE RETAINED BY AUTHORIZED RECIPIENT

COPY – PROVIDED TO SUBJECT OF CRIMINAL HISTORY RECORD CHECK if requested

Rev 2015 http://www.kansas.gov/kbi/criminalhistory http://www.fbi.gov/about-us/cjis/background-checks/background_checks http://www.fbi.gov/about-us/cjis/background-checks/background_checks

This Consumer Credit information is for your files.