Independent Agent Annual Report Of Secondary Representatives
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Independent Agent Annual Report Of Secondary Representatives 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: Independent Agent Annual Report Of Secondary Representatives, JR-10, Nevada Statewide, Nevada Gaming Commission And State Gaming Contol Board
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
STATE GAMING CONTROL BOARD
INDEPENDENT AGENT
:
ANNUAL REPORT OF SECONDARY REPRESENTATIVES
Calendar No.
(Due annually on July 15)
A.
INDEPENDENT AGENT INFORMATION:
Name
First
:
Plaintiff(s)
-against-
:
Middle
Business Address
B.
Last
:
Street Number and Name/City/State/Zip Code
Telephone No.
JUDICIAL SUBPOENA
Social Security Number
:
LICENSEE/CASINO INFORMATION (LIST ALL CASINOS YOU ARE CURRENTLY REGISTERED WITH):
Defendant(s)
:
......................................................
THE PEOPLE OF THE STATE OF NEW YORK
NOTE:
C.
Submit only one form annually directly to the Gaming Control Board regardless of the number of casinos you are
currently representing.
TOSECONDARY REPRESENTATIVE INFORMATION:
1.
Name
First
Home Address
GREETINGS:
Middle
Last
Street Number and Name/City/State/Zip Code
Employer
WE COMMAND
Position
YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
Date of Birth
Social Security No.
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
2. Name
or adjourned date, to testify First give evidence as a witness in this action on the part of the Last
and
Middle
Home Address
Street Number and Name/City/State/Zip Code
Employer
Position
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
Date of Birth
Social Security No.
result of your failure to comply.
3.
Name
First
Witness, Honorable
Home Address County,
Court in
Middle
day of
Last
, one of the Justices of the
, 20
Street Number and Name/City/State/Zip Code
Employer
Position
Date of Birth
(Attorney must sign above and type name below)
Social Security No.
**PLEASE USE AN ADDITIONAL SHEET, IF NECESSARY, TO LIST ALL SECONDARY REPRESENTATIVES**
I,
, being duly sworn, deposes and says that the above statements
Attorney(s) for
are true and correct to the best of my knowledge and belief and this statement is executed with the knowledge that
misrepresentation or failure to reveal information requested may be deemed sufficient cause for refusal to issue or revocation of
a State Gaming License. Further, that I am voluntarily submitting this filing under oath with the full knowledge that the Gaming
Control Act (NRS 463.140(5)) provides “any person making false oath in any matter before either the Board or Commission is
guilty of perjury.”
Office and P.O. Address
Signature of Independent Agent
STATE OF
ss.
COUNTY OF
SUBSCRIBED AND SWORN TO BEFORE ME
THIS
DAY OF
,
Telephone No.: (Seal, if any)
Facsimile No.:
E-Mail Address:
Mobile Tel. No.: of Notarial Officer
Signature
JR-10_Reg 25 (Rev. 09/04)
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