Form Gbi Bo2 – Fill Out and Use This PDF

FORM GBI/BO2 (04/2013)PERSONAL HISTORY & BACKGROUND

INSTRUCTIONS: This form must be executed under oath, by every officer, director, board member and person associated with operations, advertising, or promoting a bingo operation, or who has a vote within the organization on how bingo funds are expended.. TYPE OR PRINT LEGIBLY. Each question must be answered fully. This form, including a passport-size photograph for all the above individuals, must be submitted with each application for a Bingo license. Renewal license applications must include the same on any unapproved workers and all new officers listed on renewal applications.

1.	Full Name ___________________________________________________ Social Security No. __________________________________________
	First	Middle		Last
2.	Name of Organization of which this personal history is a part (include Post/Lodge/Club No.) _____________________________________________
3.	Are you a member of this organization.? YES (		) NO (	) How long have you been a member of this Post/Lodge/Club? ____________________
	Your position in organization? _________________ Salary? _______________					Type of Membership? ________________________________
						(Regular, Auxiliary, Honorary, Associate, other)
4.	Other names used by you (include maiden name) ______________________________________________________________________________
5.	BIRTHDATE _____/____/____	RACE ____ SEX ___		HEIGHT ____	WEIGHT ____ COLOR EYES ________		COLOR HAIR __________
6.	Place of Birth _______________________ Are you a U.S. Citizen? Yes (				) NO (	) By Birth? _____ Naturalized?	_____	Date ___/___/___
7.	Are you a Georgia Resident?	Yes ( ) No (	)	How long have you resided in Georgia? _______________________________________
8.	Home Address ______________________________________________________________________ Home Phone No. (_____)______________
	Street number and name			City	State	Zip	Area Code & Number
9.	Mailing Address if different from above _______________________________________________________________________________________
		(P. O. Box)			City	State		Zip

10.	Business Address __________________________________________________________________ Work Phone No. (_____)_______________
	Street	City	State	Zip	Area Code & Number
11.	Military Service ________________________________________________________________________________________________________
	Branch	Serial Number	Years of Service		Type of Discharge
12.	Single ( ) Married ( ) Other __________________ Full Name of Spouse (include maiden name) ___________________________________
	Date of Marriage:____/____/___	Spouse’s SSN _________________ Birth Date____/____/___			Employer ______________________________

13. Employment Record (in reverse chronological order) for the last five (5) years; if self employed give details of employment.

14. List in reverse chronological order all your residences for the last five years:

15. Are you a bingo worker for any other organization? YES ( ) NO ( )

List name of the previousorganization(s): _________________________________________________________________________

(Over)

16.Have you ever been convicted of a violation of any federal, state, county or municipal law? (Include pleas of

Nolo Contendere). YES ( ) NO ( ). Include traffic violations such as DUI, Homicide by Vehicle, Serious Injury by Vehicle, Fleeing or Attempting to Elude a Police Officer, and Impersonating a Law Enforcement Officer. Do not list other minor traffic violations. List the offense, date of offense, location (City or County), and provide the disposition of case (i.e., dismissed, nolle prossed, suspended, 1st offender waiver, convicted). If you have a conviction or pled Nolo Contendere, list the sentence and/or fine imposed. Use additional sheets as necessary to completely answer this question.

(1)

Offense	Date	Location	Disposition of Case	Sentence and/or Fine Imposed
(2)
Offense	Date	Location	Disposition of Case	Sentence and/or Fine Imposed
(3)
Offense	Date	Location	Disposition of Case	Sentence and/or Fine Imposed
(4)
Offense	Date	Location	Disposition of Case	Sentence and/or Fine Imposed
(5)
Offense	Date	Location	Disposition of Case	Sentence and/or Fine Imposed

_________________________________________________________________________________________________________________________

PRIVACY ACT NOTIFICATION

The Privacy Act of 1974 provides that each State agency inform individuals from whom information is solicited as to the authority for the solicitation of such information and whether disclosure of the information is mandatory or voluntary. The principal purpose for soliciting the information requested herein is to administer the State Bingo Laws and Regulations. The completion of all appropriate items is voluntary. The failure to furnish or supply information, or the furnishing of misleading or untrue information will cause denial of the bingo license applied for or denial of the applicant officer/worker of the organization shown in Item 2 hereof.

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VERIFICATION

State of Georgia, ________________________________________ County

I, ____________________________________________________________________________ do solemnly swear, subject to the penalties of false

swearing, that the statements and answers made by me in the foregoing personal statement are true.

This _________ day of ______________________, 20_______ ___________________________________________________________

Applicant’s signature (full name and in ink)

ADDITIONAL APPLICANT CONTACT INFORMATION:

Applicant’s Cellular Telephone Number: ___________________________________________________

Applicant’s Contact Email Address:____________________________________________________________________