Form Gbi Bo2 PDF Details

In Georgia, all employers with more than ten employees are required to provide workers' compensation insurance coverage for their employees. However, there are some specific exemptions to this rule, which this article will explore. Employers who do not have to provide workers' compensation insurance coverage include farm owners and farmers, household domestic workers, and casual laborers. Additionally, self-employed individuals are not required to provide workers' compensation insurance for themselves if they have no employees. Finally, churches and other religious organizations are exempt from the requirement to provide workers' compensation insurance. If you are an employer in Georgia and are unsure whether you are required to provide coverage, or if you have any other questions related to workers' compensation insurance, please contact an experienced attorney today.

QuestionAnswer
Form NameForm Gbi Bo2
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesgeorgia beuro of investigation, gbi drug submission form, gbi bo2, gbi crime lab submission

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GEORGIA BUREAU OF INVESTIGATION BINGO SECTION

P. O. BOX 370808

DECATUR, GA 30037-0808

FOR GBI USE ONLY

REGION:

FP:

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.

FROM

TO

Mo.

Yr.

Mo.

Yr.

 

 

 

 

 

 

 

 

EMPLOYER

STATE

OCCUPATION

SALARY

REASON FOR LEAVING

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

FROM

 

TO

Mo.

Yr.

Mo.

 

Yr.

 

 

 

 

 

 

 

 

 

 

STREET

CITY

STATE

ZIP

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

 

 

 

 

 

_________________________________________________________________________________________________________________________

18.Attach a passport-size photograph taken within the past two years. Write name and organization associated with on the back of photo.

Do not submit xeroxed copies of driver's licenses!

**NOTE: Before signing this statement, check all answers to see that all questions have been answered completely. This statement is to be executed under oath and is subject to the penalties for false swearing.

(Attach Photograph Here)

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.

===================================================================================================================

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:____________________________________________________________________