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Personal History Multi Jurisdictional Disclosure Form (Addendum To Form 7) 7A - Nevada
| Personal History Multi Jurisdictional Disclosure Form (Addendum To Form 7) 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 OF NEVADA GAMING CONTROL BOARD NEVADA SUPPLEMENTAL PERSONAL HISTORY DISCLOSURE FORM NONRESTRICTED GAMING LICENSE OR NONRESTRICTED KEY EMPLOYEE GAMING LICENSE American LegalNet, Inc. www.FormsWorkFlow.com STATE OF NEVADA ADDENDUM TO FORM 7 PERSONAL HISTORY MULTI-JURISDICTIONAL DISCLOSURE FORM This Addendum to be submitted in conjunction with Form 7 APPLICANT INFORMATION 1. Last Name Occupation First Name Middle Name Social Security Number 2. Name of location for which you are to be licensed, registered, or found suitable. Name of Legal Entity Position Address of Legal Entity % of Interest 3. Are you a citizen of the United States? a. b. If a non-citizen, Registration No.: If Naturalized, Certificate No: Place Yes No Date (Documentation will be necessary) 4. Have you ever had a civil or criminal record expunged or sealed by a court order? Yes No Jurisdiction: Date: Charge/Complaint: Case Number: Disposition: 5. 6. 7. Have you registered for the draft? County Source of Investment Yes State No Date Amount of Personal Investment in business $ Has your interest in this gambling establishment been assigned, pledged or hypothecated to any person, firm, or corporation, or has any agreement been entered into whereby your interest is to be assigned, pledged or sold either in part or in whole? Yes No Has your Federal Income Tax Return ever been audited? Tax Year: Audit Year: Office Conducting Audit: Yes No 8. Form 7A_Nevada Supplemental_PHD (Rev. 05/04) -1- Applicant's initial American LegalNet, Inc. www.FormsWorkFlow.com 9. Last Federal Income Tax Return was filed Date For Tax Year: Applicants are advised that Federal Income Tax Returns will be required. 10. Has any member of your family or of your spouse's family ever been convicted of a felony? Yes No If yes, complete the following: Name Relationship Charge Location Date Disposition SPOUSE INFORMATION 11. Last Name Occupation Current Employer First Name Middle Name Social Security Number 12. Is your spouse a citizen of the United States? a. b. If a non-citizen, Registration No.: If Naturalized, Certificate No: Place Yes No Date (Documentation will be necessary) -2- Applicant's initial American LegalNet, Inc. www.FormsWorkFlow.com STATE OF ss. COUNTY OF I, (Applicant's Name) , being first duly sworn, depose and say under the penalty of perjury that I have read the foregoing Form 7 and this Addendum (sometimes collectively referred to as Application) and know the contents thereof; that all statements and information of whatever kind and nature contained within the Application have been personally reviewed by me and are true and correct and contain a full account of all information requested; that I have not omitted or otherwise failed to state a material fact necessary to make the facts and statements presented within the Application not misleading; that I executed this statement with the knowledge that any untrue or misleading fact or statement or the failure to reveal all of the information requested may in itself, be sufficient to cause adverse action to be taken with regards to my Application, to and including denial, as well as revocation and/or other forms of disciplinary action against any license, approval, finding of suitability, or registration I may have been previously granted; that I am voluntarily submitting this Application with full knowledge that Nevada Revised Statutes 463.140(5) provides "[a]ny person making false oath in any matter before the Board or Commission is guilty of perjury."; and, further, that I have familiarized myself with the contents of the Nevada Gaming Control Act, as amended, and the Regulations of the Nevada Gaming Commission as promulgated thereunder and agree, if granted the license[d], registration, finding of suitability, or approval requested, to abide thereby. In consideration of the assurance that no vote will be taken by the Board and/or Commission except after a deliberate, intensive and thorough investigation of the facts and circumstances surrounding this Application, I, for myself, as well as for my heirs, executors, administrators, successors, and assigns, hereby release and forever discharge the State of Nevada, the State Gaming Control Board, the Nevada gaming Commission, the Nevada Attorney General and each of their members, agents, and employees in their individual and representative capacities, from any and all manner of actions, causes of action, suits, debts, judgments, executions, claims, and demands whatsoever known or unknown, in law or equity, that I have, ever had, may have, or claim to have against any and all of the persons or entities named in this paragraph, arising out of, or by reason of, the investigation of the facts and circumstances surrounding, or in any way relating to, this Application, any action or inaction taken or not taken as a result of, or to, this Application, or any person or entity associated or related therewith, as well as any adverse publicity, public notice, embarrassment, criticism, or financial loss which may result from, or be caused by, any of the above actions or inactions, persons or entities. I understand that this Application requesting action by the State Gaming Control Board and/or Nevada Gaming Commission, may not be withdrawn without the prior approval of the Board, and that by filing this Application, I consent to the making of a decision by the Board and/or Commission on this Application, at their election, even if this Application becomes moot for any reason other than my death. Print/Type Name of Applicant Signature of Applicant SUBSCRIBED AND SWORN TO BEFORE ME THIS DAY OF , Signature of Notary Public (SEAL/STAMP) -3- Applicant's initial American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATION OF FORM Nevada Gaming Regulation 10.010 requires that every attorney, certified public account, or other agent who prepares this document on behalf of the applicant be properly enrolled with the Commission. Regulation 10.110 requires any such representative to certify such document. If this document was prepared by such a representative, please have that person complete the following: I, (Representative's Name) , do hereby certify that I am enrolled to practice before the Nevada Gaming Commission and am fully knowledgeable of my responsibilities under Regulation 10. I further certified that I have prepared this document on behalf of the applicant in conformity with the Nevada Gaming Control Act and the Regulation of the Nevada Gam
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