Material Change Notification Form

Please be advised that the Michigan Gaming Control and Revenue Act, MCL 432.201 et. seq., and its administrative rules, Mich. Admin Code R 432.1101 et. seq., provide the following regarding your responsibility to promptly disclose any material changes in information previously provided to the Board:

Mich. Admin Code R 432.206(2):

A licensee or an applicant for a license has a continuing duty to disclose promptly any material changes in information provided to the board as soon as the applicant or licensee becomes aware of the change. The duty to disclose changes in information continues throughout any period of licensure granted by the board. A licensee or applicant shall make sure that all required release of information forms submitted to the board are current.

Mich. Admin Code R 432.1301(6)(a):

(6) An applicant and licensee shall have a continuing duty to do all of the following: (a) Notify the board of a material change in the information submitted in the license application submitted by the applicant or licensee or a change in circumstances, that may render the applicant or licensee ineligible, unqualified, or unsuitable to hold the license under the licensing standards and requirements of the act and rules.

Failure to disclose promptly any material change in information, may result in the Board initiating disciplinary action, including but not limited to, suspension or revocation of your license.

I am making changes to my:

Name Change
Address
Phone Number
Social Security Number Correction
Criminal History
Marital Status
Bankruptcy - L1 or L2 Licensee

MGCB License#

Casino

Testing checkbox

NAME CHANGE

First Name*

Last Name*

Middle Name

Previous Name(First,Middle,Last)

Position Title

Primary Email

Primary Phone

Alternate Phone

SOCIAL SECURITY NUMBER CORRECTION

Old Social Security Number

New Social Security Number

ADDRESS CHANGE

New Residence Address (Street)

City

State

Zip

Previous Residence Address (Street)

City

State

Zip

CURRENT MARITAL STATUS

Status

First Name

Last Name

Middle Name

Maiden Name

BANKRUPTCY NOTIFICATION

Type

Date Bankruptcy Filed

Date Bankruptcy Discharged

CRIMINAL HISTORY

Answer each question below as it pertains to your current criminal offenses, either felony or misdemeanor. DO NOT include civil traffic violations.

Please mark the applicable box:

I have been arrested or detained.
I have been charged with a misdemeanor or felony.
I have been convicted, pleaded guilty or no contest, or forfeited bail of a misdemeanor or felony.

If you checked any of the boxes above, please complete the sections below for each current criminal offense. (Include court register of actions, certified copy of conviction, or police agency incident report with this form)

Row Number	Nature of Offense Felony or Misdemenor	Date of Charge or Incident	Name and Address of court or police agency	Disposition	Date of Disposition
1

MICHIGAN GAMING CONTROL BOARD

Material Change Notification Form

Material change notification