Personal History Multi Jurisdictional Disclosure Form (Addendum To Form 7) {7A}

Form 7A - NEVADA SUPPLEMENTAL FORM TO THE MULTI-JURISDICTIONAL PERSONAL HISTORY DISCLOSURE FORM. This form is a supplement to the Multi-Jurisdictional Casino/Gaming License Personal History Disclosure Form (Form 7 MJPHD) If you are using the Multi-Jurisdictional Personal History Form to apply for qualification in more than one jurisdiction and one of those jurisdictions in Nevada, you are required to file this supplemental form as part of your Nevada application. The other jurisdictions where you are filing may also have supplemental forms, and it is your responsibility to obtain these forms and make the appropriate filings. Typed answers are preferred. All handwritten answers must be in BLACK ink and block lettering. Read each question carefully prior to answering, and answer every question completely to the best of your knowledge. Do not leave blank spaces, type an answer to every question. If a question does not apply to you, state with “N/A.” If there is nothing to disclose, indicate “None.” Failure to provide a response to every question could result in the denial of your application and/or lengthen the amount of time needed to complete the investigation. Applicant must initial each page, as provided in the lower right-hand corner. By placing his/her initials on each page, the applicant attests to the accuracy and completeness of the information on that page. Sign and notarize all applicable forms and pages. Applicant is advised that this is an official document, and misrepresentation or failure to reveal the information requested may be deemed sufficient cause for grounds for denial of an application or disciplinary action. Do not misstate or omit any material fact(s) as each statement made herein is subject to verification. It is the applicant's responsibility to thoroughly familiarize himself/herself with all applicable statutes, regulations, and local ordinances, rules, and regulations pertaining to the applied application. Once your application is submitted, it becomes the property of the Nevada Gaming Control Board. The applicant is advised to make copies before submitting the application. www.FormsWorkflow.com