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Independent Agents Report Of Arrangements 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 Agents Report Of Arrangements, JR-08, Nevada Statewide, Nevada Gaming Commission And State Gaming Contol Board
STATE GAMING CONTROL BOARD
INDEPENDENT AGENTS
REPORT OF ARRANGEMENTS
(Regulation 25.020)
Independent Agent
Collection Representative
Every licensee who enters into any arrangement with an Independent Agent as defined in Regulation
25 shall cause each to provide the following information:
A. Name and Address (Independent Agent)
B. Business Name (if applicable):
Business Address:
Business Type:
Sole Proprietorship
Partnership
Limited Liability Company (LLC)
Association
Corporation
Other
Attach narrative explanation if necessary.
If business, partnership, association, or LLC, give full name, address, and nature of interest of
all members thereof. If a corporation, furnish the same information for all officers, directors, or
persons who hold an ownership interest of five (5) percent or more.
Name
Address
% of Interest
1.
2.
3.
Each person listed above must submit a Personal History Record (Form 4R).
C. Do you have secondary representatives of other employees working for you?
Yes
No
If yes, attach a list of all employees including Social Security Number and date of birth.
D. Will your spouse, any member of your family or spouse’s family, have any involvement in the
operation of junket activities?
Yes
No
If yes, attach a list of all individuals involved including their Social Security Number, date of birth,
and a detailed description of their duties and relationship to Independent Agent (i.e. partner,
associate).
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E. Gaming licensee for whom customers will be arranged:
Casino Name
Address
Attach a copy of any documents evidencing the terms of any arrangement with the licensee
named above for organizing of customers or the collection of credit. If no arrangement has been
reduced to writing, attach a detailed written description of arrangements or agreements.
F. Will Independent Agent be required to guarantee any payment due a licensee from any
customer?
Yes
No
If yes, attach a completed Personal Financial Questionnaire.
G. Will Independent Agent be collecting any credit for the licensee?
Yes
No
List all persons who may be utilized for collection of any credit which the Independent Agent has
agreed to collect for a licensee.
1.
2.
3.
STATE OF
ss.
COUNTY OF
I,
, being duly sworn, depose and say that the above
Applicant’s Name
statement is executed with the knowledge that misrepresentation or failure to reveal information requested may
be deemed sufficient cause to require a Nevada gaming licensee to terminate all relationships with the
Independent Agent. Further, that he/she is 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.”
INDEPENDENT AGENT
Signature
SUBSCRIBED AND SWORN TO BEFORE ME
THIS
DAY OF
,
Notary Public
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