Oceanside Police Department

3855 Mission Avenue, Oceanside, CA 90258-1882

760-435-4650

Oceanside Police Department

Card Room Permit Application

Organization - Please select one

Oceans 11

Blackstone Gaming (Third Party Permit)

Business Connect Solutions (Third Party Permit)

Lucky Dollar Gift Shop (Third Party Permit)

Applicant Information

Social Security Number

Last Name on Social Security Card

First Name on Social Security Card

Middle Name on Social Security Card

California Driver's License

Last Name on California Driver's License

First Name on California Driver's License

Middle Name on California Driver's License

Sex

Female

Male

Birthdate

Race

Height

Weight

Hair

Eyes

Current Home Address (No PO Boxes Allowed)

Address or Location

Cell Phone Number

Email

List any other names you have ever used (Maiden, Married, Nicknames, etc.)

Birth City

Birth State

Birth Country

Languages Spoken

Criminal History

List all arrests resulting in convictions (other than infractions for traffic violations).

If additional space is needed, attach additional sheets to the application. Please note any false statements, misleading statements, or omissions on this application shall be grounds for disqualification.

Arrest Date

Date Picker

Arresting Agency / Location / Court Name

Charge / Reason for Arrest

Disposition - What was the outcome of the case? Were you sentenced? Did you have to pay a fine? Probation? Parole? Etc.?

Arrest Date

Date Picker

Arresting Agency / Location / Court Name

Charge / Reason for Arrest

Disposition - What was the outcome of the case? Were you sentenced? Did you have to pay a fine? Probation? Parole? Etc.?

Arrest Date

Date Picker

Arresting Agency / Location / Court Name

Charge / Reason for Arrest

Disposition - What was the outcome of the case? Were you sentenced? Did you have to pay a fine? Probation? Parole? Etc.?

Arrest Date

Date Picker

Arresting Agency / Location / Court Name

Charge / Reason for Arrest

Disposition - What was the outcome of the case? Were you sentenced? Did you have to pay a fine? Probation? Parole? Etc.?

Arrest Date

Date Picker

Arresting Agency / Location / Court Name

Charge / Reason for Arrest

Disposition - What was the outcome of the case? Were you sentenced? Did you have to pay a fine? Probation? Parole? Etc.?

Previous addresses for the past five (5) years and dates of residence at each

Address: including City, State and ZIP Code

Dates of Residence

From

To

Address: including City, State and ZIP Code

Dates of Residence

From

To

Address: including City, State and ZIP Code

Dates of Residence

From

To

Address: including City, State and ZIP Code

Dates of Residence

From

To

Address: including City, State and ZIP Code

Dates of Residence

From

To

Address: including City, State and ZIP Code

Dates of Residence

From

To

Address: including City, State and ZIP Code

Dates of Residence

From

To

Employment History for the past five years. List most recent first.

Employer

Employer Phone Number

Job Title

Dates of Employment

From

To

Reason for Leaving

Employer

Employer Phone Number

Job Title

Dates of Employment

From

To

Reason for Leaving

Employer

Employer Phone Number

Job Title

Dates of Employment

From

To

Reason for Leaving

Background Investigation Release

I agree to provide any information requested or deemed necessary by the State of California Department of Justice and the Federal Bureau Investigation, or any other law enforcement agency or third-party consultant authorized by the City Manager or Chief of Police.

I understand this will serve to disclose any record of arrests to which I have been the subject that resulted in conviction. I further agree to hold harmless and to defend and indemnify the City of Oceanside, its officers, agents, and employees, from any action(s), or damages whatsoever or at all, arising or resulting from the taking of such fingerprints or forwarding them to the appropriate law enforcement agency for a record’s check obtaining access to any other documentation which pertains to meeting the qualification for a Cardroom Employee Permit, or relying upon said documentation in making any decision relating to this application.

By signing this form, I acknowledge and agree to comply with all the conditions and terms of this application. I also understand that falsifying and/or omitting any information on this application may be grounds for denial of a Permit or is grounds for termination of employment per the Oceanside Ordinance.

Statement of Perjury

I declare under the penalty of perjury, under the laws of the State of California and the City of Oceanside, that the foregoing is true and correct to the best of my knowledge.

Sign Here

First Name

Last Name

Email

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

Job Title (Position Applying For)

Date

Date Picker

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