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2. 
3. Bingo Application for Operators and Officers

   Complete a separate application for each operator and/or officer.

5. Last Name*
6. First Name*
7. Middle*
9. Phone Number*
10. Birthdate*
    Birthdate
11. Alias/ Nickname

    Include any other names you may have used in the past. Include maiden names. 

13. Address*
15. City*
16. State*
17. Zip Code*
19. Are you a US Citizen?*

    1. Yes
    2. No
20. Social Security Number*
21. Driver's License Number*
22. State of Issuance*
    -- Select One --ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
24. Sex*
    -- Select One --MaleFemaleNon-Binary
25. Hair Color*
    -- Select One --BlackBrownGrayBlondeRedNo hair/ Bald
26. Eye Color*
    -- Select One --BlackBrownBlueGreenHazel
28. Height*
29. Weight*
30. List any unique personal identifying features*

    Include scars, markings, and tattoos

32. Residence History*

    List all of your residences during the last five years. Include address, city, state, zip code and the dates when you resided at each.

34. Have you ever been involuntarily committed to a hospital or institution for psychiatric examination or found not guilty for reasons of insanity in a prosecution?*

    1. Yes
    2. No
35. Explanation*
37. Have you ever been arrested for or convicted of any criminal offense?*

    1. Yes
    2. No
38. Explanation*
40. Have you ever been a mental patient in any hospital or institution?*

    1. Yes
    2. No
41. Explanation*
43. Have you ever been convicted of any traffic violation within the last five years?*

    1. Yes
    2. No
44. Explanation*
46. Name of the Organization by which you are or will be employed/ own/ volunteer?*
48. Organization Address*
50. City*
51. State*
52. Zip Code*
54. Employment/ Volunteer History*

    List in chronological order, most recent first, your employment history for the last five years preceding the date of this application and the position(s) you held. Include volunteer history if relevant.

    List employer name, address, phone number, position held and employment date range.

56. Have you withheld any information that might alter the decision to approve this permit?*

    1. Yes
    2. No
57. Do you agree and give your permission to allow a background investigation of you and the contacting of any person who may aid the investigation to determine whether the permit should or should not be issued?*

    1. Yes
    2. No
59. If the conditions under which this permit is requested should no longer exist and you have been granted a permit, do you promise to notify this department and surrender the permit if necessary?*

    1. Yes
    2. No
61. Certification

    I declare under penalty of perjury that the foregoing is a true and correct statement. I further declare under penalty of perjury that I have omitted no item requested to be answered, and have included a full and correct answer to each to the best of my knowledge and belief. I hereby authorize the Rohnert Park Department of Public Safety to make whatever inquires are necessary to verify the truth of these matters stated herein. I understand that any intentional misrepresentation of a material fact shall subject me to possible penalties for perjury, and shall be grounds to deny or revoke the permit sought by this application. 

63. Signature*

    Type First and Last Name

64. Date*
    Date
Leave This Blank:


66. 1. Receive an email copy of this form.
67. Email address

    This field is not part of the form submission.

68. Submit Submit and Print

* indicates a required field