Arrest Notification Form

Any person licensed by the Colorado Limited Gaming Control Commission, and any associated person to a licensee, must make written notification to the Division’s Lakewood office of any criminal conviction and/or criminal charge pending against such person within 10 days of such arrest, summons, or conviction. This includes:

  • Being taken into custody for any offense, including traffic offenses
  • Being issued a summons or citation for any offense except for minor traffic offenses
  • Failing to comply with your sentencing requirements
  • Failing to appear for a court proceeding and having a bench warrant issued
  • Having your driver license suspended or revoked
  • Being alleged to have driven under the influence or impairment of intoxicating liquor or drugs

Failure to disclose an arrest or citation may result in disciplinary action, up to and including the revocation of your license.

How to Submit Documentation

Please submit copies of any documentation related to this incident.  Documentation might include (but is not limited to) summonses, court paperwork, dispositions, and accident reports.  E-mail documentation to Michael Richardson at michael.richardson@state.co.us, or fax to (303) 205-1342.

Name
Arrest
Disposition Narrative - Must also provide official documentation (except for minor traffic offense)
Enter Another Arrest
Disposition Narrative - Must also provide official documentation (except for minor traffic offense)