bgc ces 0013 gambling control crime reporting formag.ca.gov/gambling/pdfs/bgc-ces-0013.pdf ·...

KAMALA D. HARRIS Attorney General State of California DEPARTMENT OF JUSTICE Bureau of Gambling Control GAMBLING CONTROL CRIME REPORTING FORM BGC-CES 0013 (Rev. 12/2011) GAMBLING CONTROL ACT (Bus. & Prof. Code, § 19800, et. seq.) CONFIDENTIAL Primary: Last Name, First, Middle AKA Address U.S. Citizen Yes No DOB Driver's Lic. No. Social Security Number CII No. FBI No. Arrest Yes No Date of Arrest Jurisdiction Case No. Name of Cardroom/Tribal Casino Address of Incident/Arrest Law Enforcement Agency Contact Person Phone No. Case Continuing Yes No ASSOCIATES Name Address DOB State ID # Prosecuting Agency Contact Person Phone No. Prosecuting No. Case Disposition Court Court Address Phone No. Court Case No. Synopsis of: (Check one:) Investigation or Prosecution Contact: Criminal Intelligence Unit P.O. Box 168024 Sacramento, CA 95816-8024 (916) 227-3584 Facsimile: (916) 227-0170 PRIVACY NOTICE The information requested on this form is being requested by the State of California, Department of Justice (DOJ), Division of Law Enforcement (DLE), Bureau of Gambling Control (BGC), for the purpose of enhancing DOJ's intelligence databases for crime statistics and trends. The maintenance of the information collected on this form is authorized by B&P Code, section 19829. All information requested on this form is mandatory. Failure to provide the requested information will result in misdemeanor criminal charges per B&P Code, Div. 8, Chpt. 5, Article 11, section 19942 subd (b). Information provided on this form may be disclosed as stated in Civil Code section 1798.24. Pursuant to Civil Code section 1798.30 et seq., individuals have the right [with some exceptions] to access records containing the personal information about themselves that are maintained by the agency. The BGC is the agency official responsible for the system of records that maintains the information provided on this form. For more information regarding the location of your records and the categories of any persons who use the information in those records, you may contact the Special Programs/BGC/Criminal Intelligence Unit, Department of Justice, at P. O. Box 168024, Sacramento, CA 95816 or via telephone at (916) 227-3584.

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KAMALA D. HARRIS Attorney General

State of California DEPARTMENT OF JUSTICE Bureau of Gambling Control

GAMBLING CONTROL CRIME REPORTING FORMBGC-CES 0013 (Rev. 12/2011)

GAMBLING CONTROL ACT (Bus. & Prof. Code, § 19800, et. seq.)

CONFIDENTIAL

Primary: Last Name, First, Middle AKA

Address U.S. CitizenYes No

DOB Driver's Lic. No. Social Security Number CII No. FBI No.

ArrestYes No

Date of Arrest Jurisdiction Case No.

Name of Cardroom/Tribal Casino Address of Incident/Arrest

Law Enforcement Agency Contact Person Phone No. Case ContinuingYes No

ASSOCIATESName Address DOB State ID #

Prosecuting Agency Contact Person Phone No. Prosecuting No. Case Disposition

Court Court Address Phone No. Court Case No.

Synopsis of: (Check one:) Investigation or Prosecution

Contact: Criminal Intelligence Unit P.O. Box 168024

Sacramento, CA 95816-8024 (916) 227-3584 Facsimile: (916) 227-0170

PRIVACY NOTICE The information requested on this form is being requested by the State of California, Department of Justice (DOJ), Division of Law Enforcement (DLE), Bureau of Gambling Control (BGC), for the purpose of enhancing DOJ's intelligence databases for crime statistics and trends. The maintenance of the information collected on this form is authorized by B&P Code, section 19829. All information requested on this form is mandatory. Failure to provide the requested information will result in misdemeanor criminal charges per B&P Code, Div. 8, Chpt. 5, Article 11, section 19942 subd (b). Information provided on this form may be disclosed as stated in Civil Code section 1798.24. Pursuant to Civil Code section 1798.30 et seq., individuals have the right [with some exceptions] to access records containing the personal information about themselves that are maintained by the agency. The BGC is the agency official responsible for the system of records that maintains the information provided on this form. For more information regarding the location of your records and the categories of any persons who use the information in those records, you may contact the Special Programs/BGC/Criminal Intelligence Unit, Department of Justice, at P. O. Box 168024, Sacramento, CA 95816 or via telephone at (916) 227-3584.

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