Form 78 9684 – Fill Out and Use This PDF

Form 78 9684 – Fill Out and Use This PDF

Form 78 9684 PDF Details

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Form 78 9684 PDF Details

Did you know that the IRS has a form specifically for churches and religious organizations? Form 78 9684 is used to solicit tax-exempt status from the IRS. This form is relatively short and easy to complete, making it a great option for churches and other religious organizations that are looking to become tax exempt. Keep in mind that there are some specific eligibility requirements that must be met in order to use this form. If you're not sure whether or not your church or religious organization qualifies, be sure to speak with an accountant or tax specialist before submitting your application. Thanks for reading!

Question	Answer
Form Name	Form 78 9684
Form Length	9 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min 15 sec
Other names	CSS FOL 78 9684E new brunswick gaming control branch background check personal disclosure form

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Department of Public Safety	Ministère de la Sécurité publique
Gaming Control Branch	Direction de la réglementation des jeux
364 Argyle Street	364 rue Argyle
P. O. Box 6000	C. P. 6000
Fredericton, NB	Fredericton (Nouveau-Brunswick)
E3B 5H1	E3B 5H1

78-9684 (06/09)

GAMING CONTROL BRANCH

BACKGROUND CHECK

PERSONAL DISCLOSURE FORM

Section A Reason for Disclosure

Under the Gaming Control Act you are required to complete a personal disclosure form.

Indicate below the name of the registrant, applicant for registration or applicant for renewal of registration to which your disclosure relates:

___________________________________________________________

Section B Identification of Individual

Last		First		Middle
Name		Name		Name

Provide any other names or aliases you have used or by which you are known (e.g. birth name, married name, nick name).

Sex	Birth date
(Male) (Female)	mm dd

Place of Birth

Social Insurance
Number	/	/

Provide a list of country(s) in which you have citizenship / hold a valid passport.

Provide a set of fingerprints taken by a police service if requested.

Current

Address

(Street

(Street Name)

(Suite / Apt /

(City)

No.)

Unit)

(Province / State)

(Country)

(Postal / Zip Code)

Telephone (

)

Facsimile (

)

Marital Status	Single	Married	Common-Law	Divorced	Separated
Marital Status

PAGE 2

Section B Identification of Individual (CONTINUED)

(A)Provide current full name and any other names or aliases used by your spouse or common- law spouse or by which your spouse or common-law spouse is known (e.g. birth name, nick name and all former married names or surname(s) if different from your surname).

(First Name)

(Middle Name)

(Last Name)

(Street No.)

(Street Name)

(Suite / Apt / Unit)

(City)

(Province / State)

(Country)

(Postal / Zip Code)

Social Insurance

Birth date

Number

(birth name, nick name, former names, etc.)

mm dd

(if applicable)

(B)Please list all other members of your immediate family including: parents, siblings (including half/step siblings and children (include step children). Attach a list if necessary.

(i)

(First Name)(Middle Name)(Last Name)

Birth date

(relationship to applicant)

(Street Number)

(Street Name)

(Suite / Apt /

(City)

Unit)

(Province / State)

(Country)

(Postal / Zip Code)

(ii)

(First Name)

(Middle Name)

(Last Name)

Birth date

(relationship to applicant)

PAGE 3

Section B

Identification of Individual (CONTINUED)

(iii)

(First Name)

(Middle Name)

(Last Name)

Birth date

(relationship to applicant)

(Street Number)

(Street Name)

(Suite / Apt /

(City)

Unit)

(Province / State)

(Country)

(Postal / Zip Code)

(iv)

(First Name)

(Middle Name)

(Last Name)

Birth date

(relationship to applicant)

(Street Number)

(Street Name)

(Suite / Apt /

(City)

Unit)

(Province / State)

(Country)

(Postal / Zip Code)

If additional space is required, please attach a separate sheet.

Section C Residence History

Provide a list of all residence(s) where you have lived for the past 10 years.

(i)

(Street No.)

(Street Name)

(Suite / Apt / Unit)

(City)

(Province / State)

(Country)

(Postal/Zip Code)

From

(mm) (yy)

(ii)

(Street No.)

(Street Name)

(Suite / Apt / Unit)

(City)

(Province / State)

(Country)

(Postal/Zip Code)

From

(mm) (yy)

(iii)

(Street No.)

(Street Name)

(Suite / Apt / Unit)

(City)

(Province / State)

(Country)

(Postal/Zip Code)

From

(mm) (yy)

PAGE 4

Section D Employment History

(A)Provide the following information for each job you have held in the last 10 years:

Current

Employer:

	(Name of employer)		(Street		(Street Name)
			No.)

(City)	(Province / State)	Country		From		To
				(mm) (yy)		(mm) (yy)

Employer:

	(Name of employer)		(Street		(Street Name)
			No.)

(City)	(Province / State)	Country		From		To
				(mm) (yy)		(mm) (yy)

If additional space is required, please attach a separate sheet.

(B) Have you ever been discharged or asked to resign from a job?	No	Yes

If yes, provide the following information on an attached sheet for each occasion in which you were discharged or asked to resign:

(i)name and address of employer;

(ii)date of discharge or resignation; and

(iii)reason for discharge or resignation.

Section E Positions of Trust

(A)Have you ever served as an officer, director or board member of a corporation or non-profit organization or served in any other position of trust?

If yes, provide the following information on an attached sheet:

(i)name and address of entity;

(ii)position held; and

(iii)dates position held.

(B)Have you ever served as a trustee for an individual, organization, corporation or non-profit organization or served in any other position of trust?

If yes, provide the following information on an attached sheet:

(i)name and address of entity;

(ii)position held; and

(iii)dates position held.

No Yes

				PAGE 5
Section E		Positions of Trust (Continued)
(C)	Have you ever been removed, discharged or asked to resign from a		No	Yes
	position of trust?		No	Yes
	position of trust?

If yes, provide the following information on an attached sheet:

(i)name and address of entity;

(ii)position held;

(iii)dates of removal, discharge or resignation; and

(iv)reason(s) for removal, discharge or resignation.

Section F Charges / Convictions / Findings of Guilt

(A)Have you ever been charged or convicted of any type of offense in any jurisdiction?

If yes, provide the following information on an attached sheet:

(i)description of charge or conviction;

(ii)date of charge or conviction (include any written judgments);

(iii)description of sentence (include any written decisions);

(iv)name and address of court; and

(v)court file number (if known).

(B)Have you any charges outstanding in any jurisdiction?

If yes, provide the following information on an attached sheet:

(i)description of charge;

(ii)date of charge;

(iii)name and address of court;

(iv)court file number (if known); and

(v)next court date.

No Yes

Section G Civil Proceedings

(A)Have you had any claim made against you in the past 10 years in any jurisdiction?

If yes, provide the following information on an attached sheet:

(i)description of claim (include statements of claim and defense);

(ii)name of other parties to the proceedings;

(iii)outcome of proceeding (include any written judgments);

(iv)date of proceedings;

(v)name and address of court; and

(vi)court file number.

(B)Are there any outstanding claim(s) filed against you or any business entity in which you are associated in any jurisdiction?

If yes, provide the following information on an attached sheet:

(i)description of the claim/

(ii)name of other parties to the proceeding;

(iii)date of proceeding;

(iv)name and address of court; and

(v)court file number.

No Yes

			PAGE 6
Section H	Permits, Licenses, Certificates and Registrations
(A) Have you, or any business entity in which you are or were associated ever		No	Yes
applied for any permit, license, certificate or registration in connection with		No	Yes

gaming in any jurisdiction?

If yes, provide the following information on an attached sheet:

(i)name and address of regulatory body;

(ii)type of permit, license or registration;

(iii)date of application; and

(iv)disposition of application (approved (terms and conditions), abandoned, withdrawn, refused).

(B)Have you or any business entity in which you are or were associated, ever had a permit, license or certificate or registration in connection with gaming refused, suspended or revoked or had any other type of disciplinary action imposed in any jurisdiction?

If yes, provide the following information on an attached sheet:

(i)name and address of regulatory body;

(ii)type of permit, license or registration;

(iii)action taken;

(iv)include copy of written decision, if any; and

(iv)date action taken.

(C)Have you or any business entity in which you are or were associated, ever had any other type of license, registration, professional designation or certification denied, suspended or revoked or had any other type of disciplinary action imposed in any jurisdiction?

If yes, provide the following information on an attached sheet:

(i)name and address of association, profession or other body of authority;

(ii)type of permit, license or certificate of registration;

(iii)action taken;

(iv)include copy of written decision if any; and

(v)date action taken.

No Yes

Section I Bankruptcy Proceedings

Have you or any business entity in which you are or were associated,

ever filed for bankruptcy, been petitioned into bankruptcy or made a No Yes proposal under any bankruptcy or insolvency law in any jurisdiction?

If yes, provide the following information on an attached sheet:

(i)name and address of the entity, if applicable;

(ii)name and address of filing party;

(iii)type of petition filed;

(iv)date of filing;

(v)name and address of trustee;

(vi)name and address of court;

(vii)court file number; and

(viii)disposition or outcome.

NOTE: Include a copy of any discharge if applicable.

			PAGE 7
Section J	Garnishment Proceedings
Have your wages, earnings or other income ever been subject to		No	Yes
garnishment, attachment or other similar orders in any jurisdiction?		No	Yes

If yes, provide the following information on an attached sheet:

(i)nature and amount of obligation;

(ii)name and address of the holder of the obligation;

(iii)name and address of court;

(iv)court file number; and

(v)current status.

Section K Attachments

List number of pages attached of additional documents (if applicable) and ensure they are clearly labeled:

Section A		Section G
Section B		Section H
Section C		Section I
Section D		Section J
Section E
Section F		Total number of pages attached

PAGE 8

NOTICE

As required by the Protection of Personal Information Act and the Right to Information Act.

In compliance with the Gaming Control Act, it may be necessary for the Registrar of Gaming Control to collect and receive additional information from any source, including from some or all of the following domestic and foreign sources: federal governments (including Canada Customs and Revenue Agency/IRS), provincial governments, state governments or municipal governments, licensing bodies, police services, other law enforcement agencies, sheriff’s offices, the Registrar of Bankruptcy, credit bureaus, trust companies, banks, professional and industry associations, former and current employers, and any government Ministry or Agency in order to complete or verify the information provided on or with this form and to determine eligibility for employment,. The Gaming Control Branch is required under the Protection of Personal Information Act and the Right to Information Act to protect the confidentiality of such information in its possession and control and to use the information only for purposes for which it is collected or for consistent purposes.

Information collected may be used and disclosed as follows:

1.To evaluate the applicant, and individuals identified in connection with the applicant, regarding their person, financial, business and criminal history, honesty and business integrity;

2.Information on the applicant, and on individuals identified in connection with the applicant, may be shared with Government officials who are assisting the Branch in the evaluation of applicants for registration;

3.The Branch may share information on the applicant, and on individuals identified in connection with the applicant, with other jurisdictions with which it makes formal agreements;

4.The Branch may share information on the applicant, and on individuals identified in connection with the applicant, with law enforcement agencies for gaming-related investigations or clearances, with other branches in the Department, including the Liquor Control Program and with the Atlantic Lottery Corporation and;

5.To conduct ongoing personal history investigations, including checks for criminal charges outstanding and past criminal convictions or criminal records, during the entire course of the applicant’s registration with the Gaming Control Branch.

I agree to give the Branch, as and when requested, any additional or written authorization that is required for the purposes of this application.

I have read and understand the above notice, I hereby consent to the direct and indirect collection of information by the Branch and consent to the use and disclosure of this information as described in the above notice.

If you have questions about the collection and disclosure of information, please call (506)-453-7472 or e- mail gaming-jeux@gnb.ca

PAGE 9

Statutory Declaration

swear/solemnly declare that

(Name)

all of the answers provided in this personal disclosure form, as well as all of the information contained in the documents and materials submitted with it, are, to the best of my knowledge and belief, true and complete.

SWORN / SOLEMNLY DECLARED BEFORE ME at )

)

		(City / Town)			(Municipality)	)
						)
						)
						)
	(State / Province)				(Country)	)
						)
						)
						)
this			day of	20		)
						)
						)
						)
						)
(Barrister, Solicitor, Commissioner of Oaths or Notary Public)						)	(Signature)

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1. While filling out the Form 78 9684, ensure to include all important fields in the associated section. It will help hasten the process, allowing your information to be processed efficiently and properly.

The right way to fill in Form 78 9684 step 1

2. When this array of fields is finished, you're ready put in the necessary specifics in Street No, Province State, Telephone, Suite Apt Unit, Country, Facsimile, Postal Zip Code, and Marital Status cid Single cid so that you can move on to the third step.

3. Completing Provide current full name and any, First Name, Street No, Province State, Street Name, Middle Name, Suite Apt Unit, Birth date, Country, Last Name, City, Postal Zip Code, Social Insurance Number if, birth name nick name former names, and mm dd is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Lots of people frequently make mistakes when completing Social Insurance Number if in this part. Remember to double-check whatever you type in here.

4. Filling in First Name, Birth date, Street Number, Province State, Middle Name, Street Name, Suite Apt Unit, Country, Last Name, relationship to applicant, City, and Postal Zip Code is essential in the fourth stage - you'll want to take the time and take a close look at every single blank area!

How you can fill out Form 78 9684 stage 4

5. To conclude your form, the particular part has some additional blanks. Filling out First Name, Birth date, Street Number, Province State, First Name, Birth date, relationship to applicant, Street Name, Suite Apt Unit, Country, Middle Name, City, Postal Zip Code, Last Name, and Section B iii will wrap up the process and you can be done before you know it!

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(Street Number)

(Street Name)

(Suite / Apt /

(Province / State)

(Postal / Zip Code)