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: