Electronic Dissemination Authorization Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Electronic Dissemination Authorization Form. This is a Nevada form and can be use in Nevada Gaming Commission And State Gaming Contol Board Statewide.
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Tags: Electronic Dissemination Authorization, Nevada Statewide, Nevada Gaming Commission And State Gaming Contol Board
STATE GAMING CONTROL
BOARD
TECHNOLOGY DIVISION
555 E. Washington Ave. #2600, Las Vegas, NV 89101
Phone: (702) 486-2043 Fax: (702) 486-2241
ELECTRONIC DISSEMINATION AUTHORIZATION
Company Name:
Company
Representative:
License #:
Title:
I request and authorize the Nevada State Gaming Control Board Technology Division to disseminate
correspondence to the above listed company electronically at the below listed email address:
Name:
Email
Address:
Phone
Number(s):
Title:
This request and authorization applies to:
Gaming device and associated equipment approvals/disapproval/rejections
General Correspondence
Other:
Terms: All correspondence will be communicated via email as an unsecured attachment. Attachments will be
formatted as an Adobe PDF file and will not be modifiable. Attachments may include proprietary and/or
confidential information.
Yes
No
I authorize the dissemination of the above listed correspondence under the terms listed
above.
(Company Name)
hereby agree to indemnify, hold harmless and defend, not excluding the State’s right to participate, the State of Nevada, the
Nevada Gaming Commission, the State Gaming Control Board, the Nevada Attorney General and each of their members,
agents, and employees in their individual and representative capacities from any and all claims against the agencies or
persons named in this paragraph, arising out of electronic dissemination of correspondence, and against all liabilities,
expenses, damages, charges and costs, including court costs and attorney’s fees, which may be sustained by the person or
agencies named in this paragraph as a result of said claims, suits and actions.
Representative
Signature:
Date Signed:
THIS AUTHORIZATION DOES NOT EXPIRE.
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