STATE OF NEVADA GAMING CONTROL BOARD EMPLOYMENT APPLICATION The State Gaming Control Board is an Equal Opportunity Employer INSTRUCTIONS 1. 2. Please print in black ballpoint pen or type filling in ALL information requested. Do not attach or substitute a résumé in lieu of this application. IF HAND PRINTED, ALL INFORMATION MUST BE LEGIBLE. 3. Failure to complete all sections may result in your application being returned for completion. This may cause considerable delay and may preclude you from exam participation. 4. FOR OFFICE USE ONLY Upon completion, please send this application to: State Gaming Control Board, P.O. Box 8003, Carson City, Nevada 89702-8003. Your application and all attachments become the property of the Gaming Control Board and cannot be returned. Therefore, original letters such as recommendations or training certificates should not be submitted with your application. Evaluator_______________________ Date___________________________ Accept Reject Title of position for which applying______________________________________________________________________________ Name______________________________________________________________________________________________________ Last First Middle Current resident address_______________________________________________________________________________________ Number Street (P.O. Box) City State Zip Current mailing address________________________________________________________________________________________ Number Street (P.O. Box) City State Zip Residence telephone (_______)__________________________ Business telephone (_______)______________________________ Mobile No. (______)_____________________ Fax No. (______)____________________ E-Mail ___________________________ Social Security No._________/_______/__________ Can you, after employment, submit verification of your legal right to work permanently in the United States? (Proof will be required.)………………………………………………………………… Yes No Criminal Conviction/Traffic Violations: Have you ever been convicted of: 1. A misdemeanor, gross misdemeanor or felony (excluding juvenile adjudication)? 2. A moving traffic violation within the last five years? Yes No Yes No If yes, attach statement giving date(s), time(s), location(s), circumstance(s), and dollar amount of fine(s). Include any conditions of your parole and/or probation, if applicable. Moving traffic violations will only be considered if driving a vehicle is a job requirement. A criminal conviction is not an automatic bar to employment. Each case is considered on its individual merits. LACK OF REQUESTED INFORMATION IS BASIS FOR REJECTING AN APPLICATION. The Gaming Control Board is, in some instances, a 24-hour, 7-day-a-week organization. You may be required to work various hours, days, or shifts, including holidays and weekends. Additionally, extensive travel may be required. Would you be willing to work under theseemployment conditions?...... Yes No The Gaming Control Board has offices throughout the State. Please mark the following geographic area(s) in which you would be willing to work: Carson City Elko Las Vegas Laughlin Reno Comments____________________________________________________________________ ____________________________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com License/Certificates: Driver’s License No.__________________________________________________State_____________________________ Class______________________Expiration date___________________________________ Professional License/Certification/Registration: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ EDUCATION Elementary/High School: Name of school last attended____________________________________________________________________________________ School address_______________________________________________________________________________________________ Number Street Circle highest grade attended: Did you graduate? 1 Yes City 2 3 4 5 6 7 8 9 10 11 Zip 12 No If you did not graduate from high school, do you have a certificate? (If “Yes” complete the following.) G.E.D. State Yes No Other___________________________________Date received_________________________Grade____________ College or University: (Please attach a copy of your college transcript.) Name of school______________________________________________________________________________________________ School address_______________________________________________________________________________________________ Number Street City Date(s) attended: From____________/__________ Month Did you receive a degree? Year Yes No State Zip To____________/__________ Month Year Degree___________________________________________Year_____________ Semester credits_______Quarters completed_______Major___________________________Minor___________________________ Graduate School: Name of school______________________________________________________________________________________________ School address_______________________________________________________________________________________________ Number Street City Date(s) attended: From____________/__________ Month Did you receive a degree? Year Yes No State Zip To____________/__________ Month Year Type of degree received______________________________Date_____________ Work taken_________________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com Business, Trade, Technical, or Vocational School: Name of school last attended____________________________________________________________________________________ School address_______________________________________________________________________________________________ Number Street City Date(s) attended: From____________/__________ Month State Zip To____________/__________ Year Month Class hours per day_______________Completed: Yes Year No Title of program or classes taken_________________________________________________________________________________ ___________________________________________________________________________________________________________ Special Training: (Courses, seminars or classes including any P.O.S.T. course(s), related to position for which you are applying.) Dates Course Title Presented by From To Hours Completed Major Emphasis of Course List professional societies, organizations, memberships and groups that are job related______________________________________ ___________________________________________________________________________________________________________ List computer hardware and software in which you have experience_____________________________________________________ ___________________________________________________________________________________________________________ EMPLOYMENT HISTORY NOTE: Beginning with your most recent employment, please complete the following information. If additional space is needed to list all of your past experience, please use additional paper maintaining the following format. From___________/________ Month Current or last employer_________________________________________________________ Year To____________/_________ Month Your title_____________________________________________________________________ Year Gross Annual Salary: Address______________________________________________________________________ Number Start: $_______________ End: $_______________ May we contact employer? Yes Street City State Zip Phone (_____)_____________________Supervisor___________________________________ No. of employees Type of business_________________________________________you supervised__________ Duties_______________________________________________________________________ No ____________________________________________________________________________ Full-time (40 Hours per week) ____________________________________________________________________________ Specific reason for leaving_______________________________________________________ Part-time (_____ Hours per week) American LegalNet, Inc. www.FormsWorkflow.com EMPLOYMENT HISTORY - (Continued) From___________/________ Month To____________/_________ Month Employer____________________________________________________________________ Year Your title_____________________________________________________________________ Year Gross Annual Salary: Address______________________________________________________________________ Number Start: $_______________ End: $_______________ Full-time (40 Hours per week) Street City State Zip Phone (_____)_____________________Supervisor___________________________________ No. of employees Type of business_________________________________________you supervised__________ Duties_______________________________________________________________________ ____________________________________________________________________________ Part-time (_____ Hours per week) ____________________________________________________________________________ Specific reason for leaving_______________________________________________________ From___________/________ Month To____________/_________ Month Employer____________________________________________________________________ Year Your title_____________________________________________________________________ Year Gross Annual Salary: Address______________________________________________________________________ Number Start: $_______________ End: $_______________ Full-time (40 Hours per week) Street City State Zip Phone (_____)_____________________Supervisor___________________________________ No. of employees Type of business_________________________________________you supervised__________ Duties_______________________________________________________________________ ____________________________________________________________________________ Part-time (_____ Hours per week) ____________________________________________________________________________ Specific reason for leaving_______________________________________________________ From___________/________ Month To____________/_________ Month Employer____________________________________________________________________ Year Your title_____________________________________________________________________ Year Gross Annual Salary: Address______________________________________________________________________ Number Start: $_______________ End: $_______________ Full-time (40 Hours per week) Street City State Zip Phone (_____)_____________________Supervisor___________________________________ No. of employees Type of business_________________________________________you supervised__________ Duties_______________________________________________________________________ ____________________________________________________________________________ Part-time (_____ Hours per week) ___________________________________________________________________________ Specific reason for leaving_______________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com If you are appointed to a Gaming Control Board position, it will be your responsibility to familiarize yourself with the restrictions, prohibitions and conditions of employment. Are you willing to proceed in obtaining this information?……………………………………………. Yes No A background investigation will be conducted in order to verify the accuracy and completeness of statements contained on the application and to obtain information relevant to predicting successful performance as a Gaming Control Board employee. Are you willing to accept this as a condition of employment?……………………………………………………………………. Yes No I DECLARE MY ANSWERS to the questions on this application are true and correct to the best of my knowledge, and I have not omitted any information. I understand any false statement or omission of information may be cause for forfeiture on my part of all rights to any employment with the Gaming Control Board. In connection with this application, I authorize the State of Nevada and any agent acting on its behalf to conduct an inquiry into any information related to my potential or continued employment with the State and authorize the release of any such information, including, but not limited to, any criminal conviction on my record. Moreover, I hereby release the State of Nevada and any agent acting on its behalf from any and all liability of whatsoever nature by reason of requesting such information from any person. ________________________________________________________________ Applicant’s Signature ______________________________ Date Revised 12/9/2005 American LegalNet, Inc. www.FormsWorkflow.com GAMING CONTROL BOARD EMPLOYMENT QUESTIONNAIRE Position Applied For: Division: Administration Enforcement Audit Investigations Corporate Securities Technology Tax & License Location: Carson City Elko Las Vegas Laughlin Reno The following information will be used by the Gaming Control Board’s Personnel Office for research and statistical purposes only. Federal and State laws make it unlawful to discriminate in employment on the basis of race, color, religion, sex, national origin, political affiliation, handicap or age. Your participation is voluntary and would be greatly appreciated. This information will be kept separate and confidential and will not be used to make any employment decision. Do you need an accommodation in the application or testing process for the job for which you are applying for any disability you may have? (It is not necessary that you describe or identify the disability.) Yes No If “Yes,” please describe the type of accommodation required: Choose one ethnic group with which you most closely identify: I. American Indian or Alaskan Native. (All persons having origins in any of the original peoples of North America and who maintain cultural identification through tribal affiliation or community recognition.) B. Black. (Not of Hispanic origin: All persons having origins in any of the Black racial groups.) A. Asian/Pacific Islander. (All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands. This area includes, for example, China, Japan, Korea, the Philippine Islands, and Samoa.) H. Hispanic. (All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin regardless of race.) W. White. (Not of Hispanic origin: All persons having origins in any of the original people of Europe, North Africa, or the Middle East.) Date of Birth: Sex: Male Female THIS FORM IS TO BE MAINTAINED BY THE GAMING CONTROL BOARD’S PERSONNEL OFFICE AND IS NOT FOR DISTRIBUTION. American LegalNet, Inc. www.FormsWorkflow.com