Personal History Multi Jurisdictional Disclosure Form (Addendum To Form 7) {7A} | Pdf Fpdf Docx | Nevada

 Nevada /  Statewide /  Nevada Gaming Commission And State Gaming Contol Board /  Investigations Division /
Personal History Multi Jurisdictional Disclosure Form (Addendum To Form 7) {7A} | Pdf Fpdf Docx | Nevada

Personal History Multi Jurisdictional Disclosure Form (Addendum To Form 7) {7A}

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

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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 Form 7A Nevada Supplemental PHD (Rev. 07/18) Page 2 of 8 STATE OF NEVADA ADDENDUM TO FORM 7 PERSONAL HISTORY MULTI-JURISDICTIONAL DISCLOSURE FORM This Addendum to be submitted in conjunction with Form 7 1. Applicant : Last Name (Include Sr., Jr., etc., if applicable) First Name Middle Name Occupation Social Security Number 2. Name of location for which you are to be licensed, registered, or found suitable . Name of Legal Entity Address of Legal Entity Position Percentage of Interest 3. A re You a Citizen of the United States? Yes No a. If a non - citizen, Registration No.: b. If Naturalized, Certificate No: (Documentation will be necessary) Date: Place: 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. Have you ever reached a settlement or had a settlement reached by another person or entity, on your behalf, prior to litigation or criminal charges having been filed against you? Yes No If yes, furnish details American LegalNet, Inc. www.FormsWorkFlow.com Form 7A Nevada Supplemental PHD (Rev. 07/18) Page 3 of 8 6. Have you ever reached a settlement or had a settlement reached by another person or entity, on behalf of a company with which you were/are affiliated, prior to litigation or criminal charges having been filed? Yes No 7. Have you registered for the draft? Yes No County: State: Date: 8. Amount of Personal Inv estment in business $ Source of Investment: 9. 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 10. Has your Federal Income Tax Return ever been aud ited? Yes No Tax Year: Audit Year: Office Conducting Audit: 11. Date last Federal Income Tax Return was filed: For Tax Year: Applicants are advised that copies of Federal Income Tax Returns will be required. 12. convicted of a felony? Yes No If yes, furnish details Name Relationship Charge Location Date Disposition American LegalNet, Inc. www.FormsWorkFlow.com Form 7A Nevada Supplemental PHD (Rev. 07/18) Page 4 of 8 13. Do you have access to a safe, safe deposit box, vault, or similar security storage in any location? (If more space is needed, provide an attachment) Yes No I f yes, provide the location(s) and description of the contents: 14. Provide a list of the business and personal e - mail accounts you have used or have had available to you in the past five years: (If more space is needed, provide an attachment) 15. Provide a list of the business and personal cell phone numbers you have used in the past five years: (If more space is needed, provide an attachment) 16. List below the number and location of electronic devices you have had access to in the past five years: (If more space is needed, provide an attachment) Device No. Locations Computers/Laptops Tablets Data Storage/Computer Networks Thumb Drives Smart Phones Other: American LegalNet, Inc. www.FormsWorkFlow.com Form 7A Nevada Supplemental PHD (Rev. 07/18) Page 5 of 8 17. Do you or you spouse store data in the Cloud or a similar service (ICloud/Drop Box)? (If more space is needed, provide an attachment) Yes No If yes, list below and provide a description of the contents: SPOUSE INFORMATION 18. Last Name First Name Middle Name Occupation Social Security Number Current Employer 19. Is your spouse a citizen of the United States? Yes No a. If a non-citizen, Registration No.: b. If Naturalized, Certificate No.: Date: Place: (Documentation will be necessary) MEDICAL/RECREATIONAL MARIJUANA INFORMATION 20. Have you or your spouse ever made an application for, or held, any Marijuana related license, permit or certification, in any jurisdiction, including but not limited to the following: dispensaries, cultivation, production, laboratories, retail, product manufacture or any other type of marijuana related approvals? If you or your spouse ever applied and the application was granted, denied, returned by the licensing agency for any reason, withdrawn or is currently pending answer Yes to this question. Yes No If yes, complete the following: Name on License Type of License Date From: Date To: Name of Licensing Agency Disposition American LegalNet, Inc. www.FormsWorkFlow.com Form 7A Nevada Supplemental PHD (Rev. 07/18) Page 6 of 8 21.Have any of the Marijuana related licenses, permits or certifications applied for, or held by you or your spouse, as identified in the previous question ever been denied, suspended, revoked or subject to any conditions in any jurisdiction? Yes No If yes, complete the following: Type of License, Permit or Certificate Name of Government Agency/Organization Date of Denial, Suspension, Revocation or Condition Reason(s) for Denial, Suspension, Revocation 22. Have you or your spouse ever made any loan which was used to finance a Marijuana related operation, license, permit or certification, in any jurisdiction? Yes No If yes, complete the following: Date of Loan Name of Borrower Original amount of Loan Type of Marijuana related enterprise the funds were used to finance 23. Have you or your spouse ever held an interest in any landlord entity owning real estate which is or has been used for a Marijuana related operation, in any jurisdiction? Yes No If yes, complete the following: Date From: Date To: Name of Entity Percentage of Ownership Type of Marijuana related enterprise and address for the Marijuana related enterprise American LegalNet, Inc. www.FormsWorkFlow.com Form 7A Nevada Supplemental PHD (Rev. 07/18) Page 7 of 8 STATE OF ss. COUNTY OF I, , 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 false oath in any matter before the Board or Commission 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 circ

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