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Personal History Record For Registering As An Independent Agent JR-12 - Nevada
| Personal History Record For Registering As An Independent Agent 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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PERSONAL HISTORY RECORD FOR REGISTERING AS AN INDEPENDENT AGENT Date GENERAL INSTRUCTIONS Type an answer to every question. If a question does not apply to you, so state with N/A. If space available is insufficient, continue on supplemental page or use a separate sheet and precede each answer with the appropriate title. Do not misstate or omit any material fact(s) as each statement made herein is subject to verification. Applicant must initial each page, as provided in lower right hand corner. By placing his/her initials on each page, the applicant is attesting to the accuracy and completeness of the information contained on that page. All applicants are advised that this Personal History Record is an official document and misrepresentation or failure to reveal information requested may be deemed to be sufficient cause for the refusal or call forward for finding of suitability regarding the applicant. All applicants are further advised that an application for filing as an independent agent, finding of suitability, or for other action may not be withdrawn without the permission of the licensing agency. 1. GENERAL INFORMATION Name of Independent Agent's business (If Applicable) From what geographic area will you draw your customer base? 2. PERSONAL INFORMATION Last Name (Surname) First Name (Given Name) Middle Name Alias(es), Nicknames, Maiden Name, Other Name Changes, Legal or Otherwise Home Address (Street #, Street Name, City, State, Country, Zip Code): Mailing Address (If Different Than Home Address): Date of Birth Place of Birth US Social Security # Passport # & Country (If No SSN): Telephone Numbers: (Area/Country Code) and Number Residence: ( ) Business: Cellular: Fax: Sex ( ( ) ) ) Color of Hair E-mail Address (Required) Company Web Address Complexion Height Weight Build ( Color of Eyes Country of citizenship If naturalized U.S. citizen, Certificate No. Place If a non-U.S. citizen, Registration No. Date (If Naturalized, document must be verified.) JR-12_Reg 25 (Rev. 01/13) -1- Applicant's Initial American LegalNet, Inc. www.FormsWorkFlow.com 3. MARITAL INFORMATION Single A. Date of Marriage Spouse's/Partner's Full Name Date of Birth Place of Birth Married Current Marriage: Place of Marriage (City/County/State/Country) Social Security #: Separated Divorced Widowed Engaged Life Partner Passport # & Country (If no SSN): Residence Address: Telephone Residence ( Business ( Spouse's Employer ) ) Occupation Address of Employer: B. Previous Marriages: Name of Spouse If ever legally separated, divorced, or annulled, indicate below: Date of Order or Divorce Decree Date and Place of Marriage Nature of Action City/County/State 4. ARREST INFORMATION Arrests, Detentions and Litigations: (List all arrests regardless of disposition, expunged or sealed.) A. Have you ever been arrested, detained, charged, indicted, or summoned to answer for any criminal offense or violation for any No reason whatsoever, regardless of the disposition of the event? (Except minor traffic citations.) Yes Age Charge Location City/State/Country Disposition and Date Arresting Agency Date of Arrest **International Applicants must submit a Certificate of Non-Criminal Conviction with this form. JR-12_Reg 25 (Rev. 01/13) -2- Applicant's Initial American LegalNet, Inc. www.FormsWorkFlow.com ARREST INFORMATION Continued B. Has a criminal indictment, information, or complaint ever been returned against you, but for which you were not arrested or in No If yes, furnish details. which you were named as an unindicted co-party? Yes C. D. E. Have you ever been questioned or deposed by a city, state, federal, or law enforcement agency, commission or committee? No Yes Have you ever been subpoenaed to appear or testify before a federal grand jury, board or commission? Have you ever had a civil or criminal record expunged or sealed by a court order? If yes, when?: city, county, and state Yes No Yes No Yes No F. Have you ever received a pardon for any criminal offense? If yes, when?: city, county, and state Yes No Location G. Has any member of your family or of your spouse's family ever been convicted of a felony? If yes, complete the following: Name Relationship Date Charge H. Have you, as an individual, member of a partnership, or owner, director, or officer of a corporation or LLC, been a party to a No (Other than divorces.) lawsuit or arbitration as either a plaintiff or defendant? Yes If yes, give details below. Description of Lawsuit Court and Case Number City, County, and State Disposition/Date Date Filed If your answer to any of the above questions (A through H) is yes, furnish details and provide copy of complaint. 5. BANKRUPTCY: A. Have you ever filed for bankruptcy? No Yes If yes, provide a copy of the bankruptcy filing and subsequent discharge. Date of Bankruptcy Location of Filing Date of Discharge JR-12_Reg 25 (Rev. 01/13) -3- Applicant's Initial American LegalNet, Inc. www.FormsWorkFlow.com 6. MILITARY INFORMATION: Have you ever served in any armed forces? Yes Branch Date of separation Rating at separation No Country: Date of entry active service Type of discharge Serial number While in the military service were you ever arrested for an offense which resulted in summary action, a trial, or special or general court No martial? Yes If yes, furnish details below. (List all incidents regardless of where they occurred foreign or domestic.) 7. EDUCATION: Name of School High School College/ University Other Type of degree obtained, if any College or University where obtained Location Dates Attended Yes Yes Graduate No No 8. FAMILY INFORMATION: A. Children and Dependents: List all children, including step-children and adopted children and give the following information: Name Birth Date Birth Place Residence Address B. Child Support Information: Please mark the appropriate response: I am not subject to a court order for the support of a child. I am subject to a court order for the support of one or more children and am in compliance with a plan approved by the district attorney or other public agency enforcing the order for the repayment of the amount owed pursuant to the order; or I am subject to a court order for the support of one or more children and am NOT in compliance with the order or a plan approved by the district attorney or other public agency enforcing the order for the repayment of the amount owed pursuant to the order. District attorney or public agency responsible for enforcing the child support or
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