Massachusetts Supplemental Form

A PHD-MA-SUPP shall be submitted by each category 1 and category 2 license qualifier in a format prescribed by the commission and may require the qualifier to provide the following information and such additional information as the commission may, in its discretion, determine: (a) Name, including maiden name and any aliases or nicknames and applicable dates of use; (b) Date of birth; (c) Physical description, including a color photograph taken within the past six months; (d) Current address, mailing and home, if different; (e) Home and work telephone numbers; (f) Social Security Number, which information is voluntarily provided in accordance with 5 U.S.C. § 552a; (g) The gaming license applicant or holding company, as applicable, with which the qualifier is affiliated, and the nature of the qualifier's position with or interest in such entity; (h) Citizenship and, if applicable, resident alien status, including any employment authorization with expiration date; country of which the qualifier is a citizen, place of birth, port of entry to the United States, and name and addresses of sponsor(s) upon the qualifier's arrival; (i) Whether during the last ten years any entity in which the qualifier has been a director, officer, principal employee or a holder of 5% or more interest has: 1. Made or been charged with (either itself or through third parties acting for it) bribes or kickbacks to any government official, domestic or foreign, to obtain favorable treatment or to any company, employee or organization to obtain a competitive advantage; 2. Held a foreign bank account or has had authority to control disbursements from a foreign bank account; 3. Maintained a bank account or other account, whether domestic or foreign, which is not reflected on the books or records of the business or which is in a name other than the name of the business; 4. Donated, loaned or used funds or property for the use or benefit of or in opposing any government, political party, candidate or committee either domestic or foreign; Compensated any of its directors, officers or employees for time and expenses incurred in performing services for the benefit of or in opposing any government or political party domestic or foreign; or Made any loans, donations or other disbursement to its directors, officers or employees for the purpose of making political contributions or reimbursing such individuals for political contributions whether domestic or foreign; (j) Copies of Federal and foreign tax returns and related information for the last five years; and (k) A signed, dated and notarized release authorization which shall direct all courts, probation departments, military organizations, selective service boards, employers, education institutions, banks, financial and other institutions and all governmental agencies, Federal, state and local, both foreign and domestic, to release any and all information pertaining to the qualifier as requested by the commission, the bureau or a contractor investigator. (l) A completed PHD-MA-SUPP shall include the following: 1. The name, address, occupation and phone number of persons who can attest to the qualifier's good character and reputation; a waiver of liability as to the Commonwealth of Massachusetts and its instrumentalities and agents for any damages resulting from any disclosure and publication of information acquired during the license or investigation process; and 3. a signed, dated and notarized affidavit.