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Independent Agent Quarterly Report JR-09 - Nevada

Independent Agent Quarterly Report Form. This is a Nevada form and can be used in Investigations Division Nevada Gaming Commission And State Gaming Contol Board Statewide .
 Fillable pdf Last Modified 6/9/2005
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STATE GAMING CONTROL BOARD INDEPENDENT AGENT QUARTERLY REPORT (Due one month after each calendar quarter) YEAR QUARTER Name of Licensee/Property: A. COMPENSATION IN EXCESS OF $20,000: Independent Agent Social Security Number Amount of Compensation 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. B. TOP 10% OF REGISTERED INDEPENDE NT AGENTS RANKED BY COMPENSATION: (Include only representatives earning $1,000 or more. Those in excess of $20,000 listed above should be included when computing the top 10%) Independent Agent Social Security Number Amount of Compensation 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 1 of 2 JR-09_Reg 25 (Rev. 09/04) <<<<<<<<<********>>>>>>>>>>>>> 2C. TERMINATED INDEPENDENT AGENTS: Independent Agent Social Security Number Date of Termination 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. I, , being duly sworn, deposes and says that the above Print Name of Preparer 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 Preparer Title STATE OF ss. COUNTY OF NOTARIZATION OF SIGNATURE HEREON SUBSCRIBED AND SWORN TO BEFORE ME THIS DAY OF , Notary Public 2 of 2
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