Form 4 Personal History Record (Rev 12/18) Page 1 of 13 Nevada Gaming Control Board Investigations Division Attention: Applicant Services PO Box 8003 Carson City, NV 89702 (775) 684-7840 Personal History Record RESTRICTED LICENSE ONLY Please read all instructions carefully before completing application. All forms can be found on our website at gaming.nv.gov: 1. Typed answers are preferred. All hand written answers must be in BLACK ink and in block lettering. Illegible application WILL NOT be accepted. 2. You must make accurate statements and include all material facts. Any misrepresentation, or the failure to provide requested information, may result in the denial of your application. 3. All applicants are advised that this Personal History Record is an official document and misrepresentation or failure to reveal information requested may be deemed to be sufficient cause for the denial of a gaming license. 4. Read each question carefully prior to answering and answer every question completely. Do not leave blank spaces, type an answer to every question. If a question does not apply to you, state with N/A. If there is nothing to disclose, indicate Failure to provide a response to every question could result in the rejection of your application and/or lengthen the amount of time needed to complete the investigation. 5. If space available is insufficient, continue on page 13 or use a separate sheet and precede each answer with the appropriate title. 6. Do not misstate or omit any material fact(s) as each statement made herein is subject to verification. 7. Applicant must initial each page, as provided in lower right hand corner. By placing his/her initials on each page, the applicant is attesting to the accuracy and completeness of the information contained on that page. 8. Additional information may be required and failure to provide the requested documents in a timely manner could result in denial of your application. 9. Once your application is submitted, it becomes the property of the Nevada Gaming Control Board. The applicant is advised to make copies before submitting the application. 10. It is the responsibility of each applicant for registration to thoroughly familiarize himself/herself with all applicable statutes, regulations, and local ordinances, rules and regulations pertaining to the particular registration applied for. 11. Attach a recent (within the past 30 days) passport size color photography of yourself. 12. Sign and notarize all applicable forms and pages. 13. Include all required attachments. 14. Provide a copy of your driver license or state issued identification card and/or passport. American LegalNet, Inc. www.FormsWorkFlow.com Form 4 Personal History Record (Rev 12/18) Page 2 of 13 PERSONAL HISTORY RECORD RESTRICTED LICENSE ONLY Date Application for: Nature of License or Finding of Suitability Desired Name and Address of Establishment for Which License is Requested Name under which it is Now Operated 1. PERSONAL INFORMATION: Last Name (Include Sr., Jr., etc., if applicable) First Name Middle Name Alias(ie, Nicknames, Maiden Name, Other Name Changes, Legal or Otherwise) Home Address: Since (Date) Apt. # City/Town State Zip Code Mailing Address (If Different Than Home Address) Apt. # City/Town State Zip Code Present Business Name Present Business Address: Apt. # City/Town State Zip Code Telephone Numbers: Occupation Residence ( ) - Business ( ) - E - Mail Address/Company Web Address (Required) Cellular ( ) - Fax ( ) - Date of Birth (Month/Day/Year) Age Place of Birth (City/County/State) US Social Security Number County and Passport Number Sex Color of Eyes Color of Hair Complexion Height Weight Build Scars, Tattoos, or Distinguishing Marks and/or Characteristics Are you a citizen of the United States? Yes No If you are a naturalized citizen of the United States or a non - citizen, you must attach a copy (front and back) of any Certificate of Naturalization, Resident Alien Card, Permanent Resident Card, Employment Authorization Document/Card, Refugee Travel Docum ent, Form I - 94, or other U.S. travel and identity document, as applicable, AND American LegalNet, Inc. www.FormsWorkFlow.com Form 4 Personal History Record (Rev 12/18) Page 3 of 13 2. MARITAL/FAMILY INFORMATION: A. Marital Information Single Married Separated Divorced Widowed Engaged Life Partner B. Current Marriage Date of Marriage Place (City/County/State) Date of Birth Place of Birth County and Passport Number US Social Security Number Residence Address Apt. # City/Town State Zip Code Telephone Residence ( ) - Business ( ) - Occupation Address of Employer City State Zip Code C. Previous Marriages If ever legally separated, divorced, or annulled, indicate below: Name of Spouse Date of Order or Decree Date and Place of Marriage Nature of Action City/County/ State D. List the names and current address of each previous spouse Name Address Street State Zip Telephone ( ) - ( ) - ( ) - E. Children and Dependents: List all children, including step - children and adopted children and give the follo wing information: Name Birth Date Birth Place Residence Address American LegalNet, Inc. www.FormsWorkFlow.com Form 4 Personal History Record (Rev 12/18) Page 4 of 13 F. Child Support Information: Please mark the appropriate response: I am not subject to a court order for the support of a child. I am subject to a court order for the support of one or more children and am in compliance with a plan approved by the distri ct attorney or other public agency enforcing the order for the repaymen t of the amount owed pursuant to the order; or I am subject to a court order for the support of one or more children and am NOT in compliance with the order or a plan appro ved by the district attorney or other public agency enforcing the order for the repayment of the amount owed pursuant to the order. District attorney or public agency responsible for enforcing the child support order: Name Address Contact Person G. Parents List names, residence address, dates of birth, and most recent occupations of parents, par ents - in - law, or legal guardian. If retired or deceased, list last address and occupation. Name (Maiden) Birth Date Address Occupation Father Mother Father - in - Law Mother - in - Law H. Brothers a nd Sisters List names, residence address, dates of birth, and most recent occupations of brothers and sisters and of their respective sp ouses. Name (Maiden) Birth Date Address Occupation Sibling Spouse Sibling Spouse Sibling Spouse Sibling Spouse 3. EDUCATION Name of School Location Dates Attended Graduate Grammar School Junior High School High School Yes No College/ University Yes No Other Type of degree obtained, if any College or University where obtained American LegalNet, Inc. www.FormsWorkFlow.com Form 4 Personal History Record (Rev 12/18) Page 5 of 13 4. MILITARY INFORMATION : A. Have you registered for the Selective Service? Yes No Country State Date registered B. Have you ever served in any armed forces? Yes No Branch Date of entry active service Date of separation Type of discharge Rating at separation Serial number While in the military service were you ever arrested for an offense which resulted in summary action, a trial, or special or general court martial? Yes No If yes, furnish details on page 13 . (List all incidents regardless of where they occurred foreign or domestic.) 5 . ARRESTS, DETENTIONS, LITIGATIONS, LIENS, AND ARBITRATIONS: For the purpose of these questions: r for the alleged n official custody, typically for questioning about a crime. to charge with a crime by the finding or presentment of a jury (such as a gran d jury) in due form of law . misdemeanors, disorderly person offenses, petty disorderly offenses, driving while intoxicated/impaired motor vehicle offenses, violations of probations or any ot her court order. You did not commit the offense charged. The charges were dismissed or subsequently downgraded to a lesser charge. You completed a pretrial intervention that dismissed or downgraded your original charge(s). You were not convicted. You did not serve any time in prison or jail. The charges or offenses happened since the age of 18 . A. H