Skip to main content

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:


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:

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 NumberNature of Offense Felony or MisdemenorDate of Charge or IncidentName and Address of court or police agencyDispositionDate of Disposition