Filling out the CGCC-030 form is a critical step for anyone looking to operate within California's gambling sector. This form, issued by the California Gambling Control Commission, is the gateway to obtaining a state gambling license, whether you're applying for the first time or seeking renewal. Detailed and accurate completion is crucial, covering everything from basic applicant information to more specific details about the gambling establishment. Applicants must decide the type of license they need, specify their entity type, and provide comprehensive information about themselves and their operations. An authorized representative can submit the application on behalf of the applicant, making the process more flexible for corporations or businesses. The declaration section reaffirms the importance of honesty and completeness, as the information provided is under the scrutiny of perjury laws in California. Alongside a $500 application fee, applicants must navigate a series of instructions ensuring they submit a complete application packet, with additional materials as required by regulatory guidelines. This comprehensive approach ensures that every applicant is thoroughly vetted, upholding the integrity of California's gambling industry.
| Question | Answer |
|---|---|
| Form Name | Form Cgcc 030 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | CGCC 030 App for State Gambling License rev. 10 cgcc 030 form |
State of California
California Gambling Control Commission
CGCC – 030 (Rev. 09/03 10/04)
Commission Use Only Fee Received:_____________
Date to DGC:_____________
APPLICATION FOR STATE GAMBLING LICENSE
Please refer to the instructions when completing the application. Type or print (in ink) all information requested on this application form. If additional space is needed, please note response on a separate sheet of paper and attach to the application.
SECTION 1: |
TYPE OF LICENSE |
Initial |
Renewal |
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SECTION 2: |
ENTITY TYPE |
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SECTION 3: |
APPLICANT AND ESTABLISHMENT INFORMATION |
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Applicant’s Full Legal Name: |
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Gender: Male |
Female |
N/A |
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Other Names: |
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Name of Gambling Establishment: |
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Business Address: |
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Street |
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City |
State |
Zip Code |
Mailing Address (if different than Business Address): |
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Street |
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Zip Code |
Business Telephone Number: |
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Business Facsimile Number (if applicable): |
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SECTION 4: AUTHORIZED REPRESENTATIVE
I have been authorized by _______________________________________________________ to submit this application.
SECTION 5: DECLARATION
I declare under penalty of perjury under the laws of the State of California that the foregoing information, and all information submitted with this application is true, correct, and complete.
Applicant/ Authorized Representative Signature:_______________________________________________________________
Print Name: |
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Date: |
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Title: |
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Designated Agent Name |
Telephone Number: |
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APPLICATION FOR STATE GAMBLING LICENSE INSTRUCTIONS
Retain a photocopy of the complete application packet for your permanent records. A separate application and fee is required for each applicant. Applications not fully and accurately completed (including all required supporting materials) will be returned to the sender for completion. If the application is returned at any point in the processing, the applicant will need to follow the directions included with it and resubmit it in a timely manner. The applicant is responsible for providing the appropriate information needed to determine eligibility for the issuance of a State Gambling License each time an application is submitted. If a question is not applicable, indicate with “N/A.” If additional space is needed, use a separate sheet of paper and precede each response with the applicable section and item. Attach the paper to the back of the application. Do not misstate or omit any material fact(s) as each statement made herein is subject to verification. Any corrections, changes or other alterations must be initialed and dated by the applicant. If any or all information is not provided, the application may be delayed, returned for completion, or denied.
Items required for the application to be considered complete:
•Application for State Gambling License
•A
In addition to completing this application, applicants must also furnish supplemental information as required by Title 4, California Code of Regulations, section 12270. See, especially, the form entitled Instructions to Applicants,
SECTION 1: TYPE OF LICENSE
Indicate whether you are applying for an initial or a renewal license by checking the appropriate box.
SECTION 2: ENTITY TYPE
Indicate the entity type from the list below: |
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Sole Proprietor |
Shareholder |
Limited Liability Company (LLC) |
Partnership |
Corporation |
LLC Member |
General Partner |
Limited Partnership |
Limited Partner |
Joint Venture |
Trustee |
Trust (specify type) |
Director |
Beneficiary |
Financial Interest |
Funding Source |
Corporate Interest Trust |
Officer |
Landlord |
Community Property Interest |
Other Interest |
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If “other interest,” enter the entity type in the blank provided in Section 2.
SECTION 3: APPLICANT AND ESTABLISHMENT INFORMATION
If applying as an individual, provide your full legal name and any other names (aliases, etc.). If applying as a business entity, provide the legal name of the entity and any alternative names for the same business entity. You must notify the Commission of any name, address or telephone number changes. Your information is used to provide proper identification of your file, to contact you, and/or to determine your eligibility. Personal information contained in the Application for State Gambling License CGC- 030 may be disclosed to the public in accordance with the Gambling Control Act (Business and Professions Code section 19821(b)).
SECTION 4: AUTHORIZED REPRESENTATIVE
If the gambling establishment is a sole proprietorship and the sole proprietor signs the application in Section 5, then indicate “N/A” in Section 4. If, however, the sole proprietor elects to designate a specific individual as an authorized representative for the purposes of the application, then the name of the sole proprietor should be entered in the space provided in Section 4 of the application. If a corporation or other business entity owns the gambling establishment, then the name of the business entity must be entered in the space provided in Section 4.
SECTION 5: DECLARATION
Sign and date the application under penalty of perjury. An application must be signed and dated to be considered complete. The designated agent information must also be included, if applicable.