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This is a Nevada form that can be used for Enforcement Division within Statewide, Nevada Gaming Commission And State Gaming Contol Board.
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STATE OF NEVADA GAMING CONTROL BOARD 1919 College Parkway, P.O. Box 8003, Carson City, Nevada 89702 555 E. Washington Avenue, Suite 2600, Las Vegas, Nevada 89101 3650 S. Pointe Circle, P.O. Box 31109, Laughlin, Nevada 89028 557 W. Silver Street, Suite 207, Elko, Nevada 89801 9790 Gateway Drive, Suite 100, Reno, Nevada 89521 750 Pilot Road, Suite H, Las Vegas, Nevada 89119 A.G. BURNETT, Chairman SHAWN R. REID, Member TERRY JOHNSON, Member BRIAN SANDOVAL Governor REQUEST FOR NEW TABLE GAME REVIEW PERSONAL HISTORY RECORD Table Game Approval for Unlicensed Applicants General Instructions * Type or print an answer to every question, if a question does not apply to you, so state with N/A. * If space available is insufficient, use a separate sheet and precede each answer with the appropriate title. * Do not misstate or omit any material fact(s) as each statement made herein is subject to verification. * Applicants must initial each page, as provided in the form's upper right hand corner. (By placing initials on the page, the applicant is attesting to the accuracy and completeness of the information contained on that page.) * All applicants are advised that this Personal History Record is an official document. Misrepresentation or failure to reveal requested information may be deemed as sufficient cause for the applicant to be called forward for a finding of suitability by the Nevada Gaming Commission. * A Personal History Record must be completed by each Executive, Officer / Director and/or Equity Holder of greater than 10% or Key Employee of the developing corporation, limited liability company, partnership, etc. Federal and State laws make it unlawful to discriminate on the basis of race, color, religion, sex, national origin, handicap or age. Name of Game: Type of Business Entity: Business Name: Business Address: City: State: Zip Code: EIN: EIN: ENF-104 (Rev. 2/11) American LegalNet, Inc. www.FormsWorkFlow.com Initials__________ A. PERSONAL INFORMATION: Last Name: First: Middle: Alias (e.g., nicknames, name changes, maiden name): Residence: Mailing Address: Business Address: Telephone Numbers (w/area code): Residence: Business: Cellular: Fax: Date of Birth: Sex: Eye Color: E-Mail Address: Place of Birth (City, County, State): Hair Color: Height: Social Security Number: Weight: Apt. #: Apt. #: Suite #: City/Town: City/Town: City/Town: Occupation: State: State: State: Zip Code: Zip Code: Zip Code: Female B. ARREST, DETENTIONS, LITIGATIONS, AND ARBITRATIONS: 1. Yes* No Have you ever been arrested, detained, charged, indicted, or summoned to answer for any criminal offense or violation for any reason whatsoever, regardless of the disposition of the event? (Except minor traffic citations) *If you answered yes, please provide details in the space listed below: (Please include all arrests, including those in which you were not convicted. Continue on a separate sheet of paper if necessary.) Date of Arrest Charge Arresting Agency City & State Disposition & Date 2. Yes* No Has a criminal indictment, information, or complaint ever been returned against you, for which you were not arrested or in which you were named as an un-indicted co-party? *If yes, please furnish details on a separate sheet of paper. 3. Yes* No Have you ever been questioned or deposed by a city, county, state, federal law enforcement agency or commission or committee? (Except the Nevada Gaming Control Board and Commission.) *If yes, please furnish details on a separate sheet of paper. Page 2 of 7 American LegalNet, Inc. www.FormsWorkFlow.com Initials__________ 4. Yes* No Have you ever been subpoenaed to appear or testify before a federal, state, or county grand jury on a civil or criminal matter? Or before a Board or Commission on an administrative issue? *If yes, please furnish details on a separate sheet of paper. 5. Yes* No Have you ever had a civil or criminal record expunged or sealed by a court order? City, County and State *If yes, when? 6. Yes No Have you ever received a pardon or deferred prosecution for any criminal offense? City, County and State *If yes, when? 7. Yes* No Have you, as an individual, member of a partnership, owner, director, or officer of a corporation, ever been a party to a lawsuit as either a plaintiff or defendant or arbitration as either a claimant or respondent? *If you answered yes, please provide details in the space listed below: Plaintiff/Defendant or Claimant/Respondent Date Filed Court and Case Number City, County & State Disposition & Date 8. Yes* No Has any general partnership, business venture, sole proprietorship, or closely held corporation (while you were associated with it as an owner, officer, director, or partner) been a party to a lawsuit, arbitration, or bankruptcy? *If yes, give details below and on a separate page if necessary. Name of Entity Type of Entity Approximate Date(s) of Lawsuit/Arbitration/Bankruptcy Page 3 of 7 American LegalNet, Inc. www.FormsWorkFlow.com Initials__________ C. RESIDENCES: List your current and previous residence: From To (month/year) From To (month/year) From To (month/year) From To (month/year) Street: Apt. #: City/Town: State: Zip Code: Street: Apt. #: City/Town: State: Zip Code: Street: Apt. #: City/Town: State: Zip Code: Street: Apt. #: City/Town: State: Zip Code: D. EMPLOYMENT: List your current employment: Month & Year (From To) Name/Mailing Address of Employer/Business Reason for Leaving Title Name of Supervisor Description of Duties Gaming Related Position? Yes No E. OTHER: 1. Have you ever held a privileged or professional license in any state, including but not limited to the following types of licenses: Liquor Accountant Doctor Race Horse/ Race Dog Owner Boxing Promoter Lawyer Jockey Trainer or Manager Real Estate Broker or Salesman Other State where, years licensed and the nature of any disciplinary actions taken against you: Page 4 of 7 American LegalNet, Inc. www.FormsWorkFlow.com Initials__________ 2. Yes* No Have you ever held a financial interest in a gambling venture, including a race track, dog track, race horse or dog, lottery, casino, bookmaking operation, or pari-mutuel operation, OUTSIDE the state of Nevada? *If yes, state when and where and give names and locations of businesses in which you are/were involved and the names and addresses of all partners: 3. Yes* No Have you ever appeared before a licensing agency or similar authority in or outside the state of Nevada, for any reason whatsoever? *If yes, ind