Nevada > Statewide > Nevada Gaming Commission And State Gaming Contol Board > Investigations Division
Application For A Nevada Gaming License 1 - Nevada
| Application For A Nevada Gaming License Form. This is a Nevada form and can be used in Investigations Division Nevada Gaming Commission And State Gaming Contol Board Statewide . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
APPLICATION FOR A NEVADA GAMING LICENSE (To be typewritten or printed legibly) A. NAME OF APPLICANT Federal Tax I.D. No. Name of Gaming Establishment Physical Address of Gaming Establishment Mailing Address B. If location has previously been licensed, please indicate former name. C. Individual Applicants: (Include name, percentage of interest, and/or position.) Attach additional sheet if necessary D. TYPE OF LICENSE: Restricted (1-15 devices only) Nonrestricted (over 15 devices and/or live gaming) E. PLEASE MARK APPROPRIATE NUMBER(S): 1. New License at Location (Proposed date of opening 2. Application for Interest in Existing License: Purchased From: 3. 4. 5. 6. 7. 8. Officer Treasury Director Individual ) % / Number of shares/units Other (Please specify) Key Employee Title(s) Written Employment Agreement: Yes No (If yes, attach a copy of the agreement.) Slot Route Operator (Do Not Check if Space Lease Application) Manufacturer Distributor Finding of Suitability: Lender Landlord Other (Please specify) Other: (Please specify) F. NOTE: If this application is for 2, 3, or 7, signature of a present licensee is required: Signature Name (Print) Title G. Breakdown of Games and Gaming Devices. To be completed when the application is for a new location: GAMES NO. TABLES NO. GAMING DEVICES NO. Craps ............................. Roulette ......................... Twenty-one .................... Keno .............................. Bingo.............................. Wheel of Fortune ........... Baccarat......................... Pai Gow ......................... Race Book ..................... Pari-Mutuel? (Yes/No) Sports Pool .................... Pari-Mutuel? (Yes/No) Other (describe): TOTAL........................ Panguingui ...................... Poker ............................... Other (describe): 5¢ ............................... 10¢ ............................... 25¢ ............................... 50¢ ............................... $1 .................................. $5 .................................. $25 ................................ $100 .............................. Multi-denominational ..... Other (describe): TOTAL .................... TOTAL .................... Progressive Slots Total Form 1_Application (Rev. 1/11) 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com H. FEE(S) TO ACCOMPANY THIS APPLICATION: STATE (To be paid to Nevada Gaming Control Board): (a) Restricted Application - $150 per applicant and/or entity, plus appropriate investigative fee (b) Nonrestricted Application - $500 per applicant and/or entity COUNTY: CITY: NOTE: APPROPRIATE BACK-UP MATERIAL MUST ACCOMPANY THIS APPLICATION TO STATE, CITY, AND/OR COUNTY, WHERE APPLICABLE. STATE OF ss. COUNTY OF I, Applicant's Name , being duly sworn, depose and say that the above statements are true and correct to the best of my knowledge and belief and that this statement is executed with the knowledge that misrepresentation or failure to reveal information requested may be deemed sufficient cause for the refusal to issue a gaming license by a municipality, or by a county or by the State of Nevada. Further, that I am aware that later discovery of an omission or misrepresentation made in the above statements may be grounds for the revocation of a gaming license. Further, that I am voluntarily submitting this application under oath with full knowledge that the Gaming Control Act (NRS 463.140(5)) provides that "Any person making false oath in any matter before either the board or commission is guilty of perjury." I am voluntarily submitting this application under oath with full knowledge that I may be required to submit this application to appropriate municipal and county authorities charged by law with granting gaming licenses. APPLICANT Signature SUBSCRIBED AND SWORN TO BEFORE ME THIS DAY OF , Notary Public NOTICE THIS APPLICATION MAY NOT BE WITHDRAWN WITHOUT THE PERMISSION OF THE LICENSING AGENCY 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com
|
|||||||
