Nevada > Statewide > Nevada Gaming Commission And State Gaming Contol Board > Investigations Division
Independent Agent Annual Report JR-10 - Nevada
| Independent Agent Annual Report Form. This is a Nevada form and can be used in Investigations Division Nevada Gaming Commission And State Gaming Contol Board Statewide . |
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STATE GAMING CONTROL BOARD INDEPENDENT AGENT ANNUAL REPORT (Due on or before July 15) INTSTRUCTIONS: This form must be filed annually by July 15. Only one form per independent agent is required regardless of the number of casino registrations. If you do not have any Secondary Representatives as defined in Section B, check the box below and complete Section A only. Be sure to sign the form and have it notarized. I do not have any Secondary Representatives at this time A. INDEPENDENT AGENT INFORMATION: Name Last (Family) First (Given) Middle Business Name/Address Street Number and Name/City/State/Country/Zip Code Social Security Number or Country and Passport Number B. SECONDARY REPRESENTATIVE INFORMATION: 1. Name Last (Family) First (Given) ______________________ Middle Home Address Street Number and Name/City/State/Country/Zip Code Date of Hire/Position Social Security No. or Country and Passport No. 2. Name Last (Family First (Given) Duties ___Date of Birth ____________________ ____________________ Middle Home Address Street Number and Name/City/State/Country/Zip Code Date of Hire/Position Social Security No. or Country and Passport No. 3. Name Last (Family First (Given) Duties____ ____Date of Birth ____________________ ___________________ Middle Home Address Street Number and Name/City/State/Zip Code Date of Hire/Position Social Security No. or Country and Passport No. Duties___ ____________________ ____Date of Birth________________________ **PLEASE USE AN ADDITIONAL SHEET, IF NECESSARY, TO LIST ALL SECONDARY REPRESENTATIVES** I, , being duly sworn, deposes and says that the above statements are true and correct to the best of my knowledge and belief and this statement is executed with the knowledge that misrepresentation or failure to reveal information requested may be deemed sufficient cause for refusal to issue or revocation of a State Gaming License. Further, that I am voluntarily submitting this filing under oath with the full knowledge that the Gaming Control Act (NRS 463.140(5)) provides "any person making false oath in any matter before either the Board or Commission is guilty of perjury." Signature of Independent Agent STATE OF ss. COUNTY OF SUBSCRIBED AND SWORN TO BEFORE ME THIS DAY OF , Signature of Notarial Officer (Seal, if any) JR-10_Reg 25 (Rev. 01/12) American LegalNet, Inc. www.FormsWorkFlow.com
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