Application For A Nevada Gaming License {1} | Pdf Fpdf Docx | Nevada

 Nevada /  Statewide /  Nevada Gaming Commission And State Gaming Contol Board /  Investigations Division /
Application For A Nevada Gaming License {1} | Pdf Fpdf Docx | Nevada

Application For A Nevada Gaming License {1}

This is a Nevada form that can be used for Investigations Division within Statewide, Nevada Gaming Commission And State Gaming Contol Board.

Alternate TextLast updated: 4/9/2019

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Form 1 Application for a Nevada Gaming License (Rev 05/18) Page 1 of 3 NEVADA GAMING CONTROL BOARD APPLICATION FOR A NEVADA GAMING LICENSE BY AN INDIVIDUAL A. Name of Individual Applicant: Full Name Last First Middle Mailing Address Street Address Apartment/Unit # City State ZIP Code Physical Address Street Address Apartment/Unit # City State ZIP Code Phone Email (Required) B. Name of Gaming Establishment: Gaming Establishment Address Street Address Suite / Unit # City State ZIP Code Federal Tax I.D. No. C. Type of License /Approval : Nonrestricted gaming ( 15+ devices and/or live gaming ) Officer Title ( If this application is for interest in existing license, signature of a present licensee is required ) Director Title ( If this application is for interest in existing license, signature of a present licensee is required ) Shareholder Total percent % Number of shares/units Purchased From: Treasury Individual ( If this application is for interest in existing license, signature of a present licensee is required ) Key Employee Title ( S ignature of a present licensee is required ) Member Total percent % Number of shares/units Purchased From: Treasury Individual ( If this application is for interest in existing license, signature of a present licensee is required ) Man a ger ( If this application is for interest in existing license, signature of a present licensee is required ) Signature of Licensee Print Name Title American LegalNet, Inc. www.FormsWorkFlow.com Form 1 Application for a Nevada Gaming License (Rev 05/18) Page 2 of 3 Restricted gaming ( 1 - 15 devices only ) Officer Title ( If this application is for interest in existing license, signature of a present licensee is required ) Director Title ( If this application is for interest in existing license, signature of a present licensee is required ) Shareholder Total percent % Number of shares/units Purchased From: Treasury Individual ( If this application is for interest in existing license, signature of a present licensee is required ) Key Employee Title ( S ignature of a present licensee is required ) Member Total percent % Number of shares/units Purchased From: Treasury Individual ( If this application is for interest in existing license, signature of a present licensee is required ) Manager ( If this application is for interest in existing license, signature of a present licensee is required ) Signature of Licensee Print Name Title Interest in Existing License Total percent % Number of shares/units Purchased From: Treasury Individual Signature of Licensee Print Name T T itle Finding of Suitability Participation in Gaming Revenue (S ignature of a present licensee is required ) Signature of Licensee Print Name T T itle Other D. Fee(s) to accompany this application (To be paid to Nevada Gaming Control Board): Send a check or money order in the amount of $500 (non - refundable application fee) for the following: Nonrestricted Officer Nonrestricted Member Nonrestricted Director Nonrestricted Manager Nonrestricted Shareholder Nonrestricted Member/Manager Nonrestricted Key Employee Nonrestricted Interest in Existing License Send a check or money order in the amount of $700 ($150 a pplication fee/$550 investigative f ee) for the following: Restricted Officer Restricted Member Restricted Director Restricted Manager Restricted Shareholder Restricted Member/Manager Restricted Key Employee Restricted Interest in Existing License American LegalNet, Inc. www.FormsWorkFlow.com Form 1 Application for a Nevada Gaming License (Rev 05/18) Page 3 of 3 THE OBLIGATIONS HEREIN CONTAINED ARE NOT INTENDED TO BE COMPLETE. CITY, COUNTY AND NEVADA LAWS AND REGULATIONS MUST BE FOLLOWED AND ARE APPLICABLE AT ALL TIMES. I, , 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 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. A PPLICANT Signature S TATE OF C OUNTY OF (SS) S UBSCRIBED AND S WORN TO ( OR A FFIRMED ) B EFORE ME O N T HIS D AY OF , S IGNATURE OF N OTARY P UBLIC M Y C OMMISSION E XPIRES (SEAL) NOTICE THIS APPLICATION MAY NOT BE WITHDRAWN WITHOUT THE PERMISSION OF THE LICENSING AGENCY DURING THE COURSE OF THE INVESTIGATION OF THE APPLICATION, AN APPLICANT MAY BE REQUIRED TO UNDERGO A DRUG TEST. REFUSAL TO UNDERGO A DRUG TEST COULD BE DEEMED GROUNDS FOR DENIAL, PURSUANT TO NRS 463.170 AND NGC REGULATION 4.040. American LegalNet, Inc. www.FormsWorkFlow.com

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