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Location-Landlord Information Sheet Form. This is a Nevada form and can be use in Nevada Gaming Commission And State Gaming Contol Board Statewide.
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Form 15 Location Landlord Information Sheet (Rev 03/18) Page 1 of 6 LOCATION / LANDLORD INFORMATION SHEET (Please attach additional sheets as may become necessary) 1. Location Name: (as it appears on the Certificate of Fictitious Firm Name and on the application): 2. Location Address Street Address Apartment/Unit # City State ZIP Code 3. Owner of Business (type of business entity and entity name): Corporation General Partnership Limited Partnership Sole Proprietor Franchisee Limited Liability Company Other Name of entity Mailing Address Street Address Apartment/Unit # City State ZIP Code Contact Person Last First M.I. Phone Email List ALL officers, directors, shareholders, members, managers, partners, proprietors, minority interest holders, etc. Name Date of Birth Social Security No. Position % of Interest (Additional information may be provided on a separate sheet of paper.) 4. Real Property Owner: (Include information regarding the owner of the building if different than the owner of the real property) Corporation General Partnership Limited Partnership Sole Proprietor REIT Limited Liability Company Publicly Traded Company Other Name of entity American LegalNet, Inc. www.FormsWorkFlow.com Form 15 Location Landlord Information Sheet (Rev 03/18) Page 2 of 6 The following information is required, pursuant to NRS 463.162(5) and NGC Regulation 3.020(2), and must be provided before the application can be processed. The property owner may provide the information directly to the Gaming Control Board, if desired. All information required to be furnished by the Board will be held in confidence and treated as confidential, pursuant to NRS 463.120(4). In the following table, list ALL officers, directors, shareholders, members, managers, partners, etc., to include, but not limited to, persons or entities owning, holding, having, or controlling an effective interest of greater than 10%: (The date of birth is required for determining identity of persons with similar names.) Name Date of Birth (MM/YY) Residence if for a Person / Location if for an Entity (STATE) Position % of Interest (Additional information may be provided on a separate sheet of paper. An organization chart may be provided for complicated ownership structures.) Include an executed Landlord Sworn Statement (utilizing the attached forms) and copies of any and all lease agreements, sublease agreements, or other documents evidencing your rights to the premises. 5. Type of Business: (i.e.: Bar / Tavern / Saloon /Convenience Store / Grocery Store / Drug Store / Liquor Store, Other): (Attach, on a separate sheet of paper, a meaningful narrative written description of the primary business) 6. Live Entertainment: Yes No a. Will there be a cover charge or drink minimum during periods of live entertainment? Yes No b. What is the maximum occupancy allowed in the establishment? 7. Mark the appropriate other services offered at the location: Check Cashing Services Short Term Loans (aka: payday loans) Wire Transfer Services 8. Type of liquor license: On Sale Off Sale Beer and Wine Only a. Status: Approved Pending Temporary b. Application to be submitted on 9. Indicate the city or county which has local licensing authority for this location What dates were applications made to local authority for: Gaming license Liquor License If the location is in the unincorporated area of Clark County, an application must be made and the applicants must submit to a personal and location suitability investigation independent of that conducted by the State. Clark County Code 8.04.030, subsection 2, requires that the application be filed with Clark County within ten (10) working days after application with the State Gaming Control Board. If the location is within the jurisdiction of the City of Las Vegas, Las Vegas Municipal Code 6.40.090 also requires that an applicant submit to a suitability investigation independent of that conducted by the State. The City of Las Vegas recommends that you submit the City of Las Vegas gaming application within thirty (30) days of application with the State Gaming Control Board. American LegalNet, Inc. www.FormsWorkFlow.com Form 15 Location Landlord Information Sheet (Rev 03/18) Page 3 of 6 If the location is in a city or county other than Las Vegas or Clark County, contact the city or county in which the business operates or plans to operate, for any additional licensing requirements which the local jurisdiction may have in relation to gaming. 10. What percentage of business patrons do you expect to be minors? 11. Indicate what hours and what days your business will operate: 12. If the property is under construction/remodel, what date do you expect the construction to be completed? Note: NGC Regulation 3.040 indicates: No license will be issued for use in premises under construction until the calendar quarter in which gaming operations in such premises will actually be commenced. 13. Provide the following information for the on-site manager(s): Name Date of Birth Social Security No. 14. Names of owners/employees who will count the gaming revenue: 15. If dollar gaming devices are to be used in the operation, check any of the following which will be used: Eisenhower Dollars Tokens Bill Acceptors TITO System 16. Source of Gaming Devices: Purchase (provide contract of sale) Lease (provide copy of lease) Participation (provide copy of agreement) Other (explain) (i.e.: provide copy of a Space Lease Agreement) 17. Sharing in Revenue: If gaming revenues are to be split/shared with others, including, but not limited by, loan agreement, lease agreement, participation agreement, or space lease agreement, please explain (i.e.: 50%/50%, 60%/40%, etc.) 18. Progressive Devices: No Yes - Number of Progressive Systems System 1 System 2 System 3 Number of devices in each system ................ Denomination of coin in each system ............ Minimum progressive jackpot amount ............ Maximum progressive jackpot amount ........... Who will maintain cash reserves? Who will maintain the daily reporting requirements identified in NGC Regulation 5.110? American LegalNet, Inc. www.FormsWorkFlow.com Form 15 Location Landlord Information Sheet (Rev 03/18) Page 4 of 6 19. Diagram: Along with your application, you must submit an original floor plan. The minimum criteria follows: a. from the edge on all sides. Computer generated or professionally drawn diagrams are preferred, but architectural drawings are not acceptable due to the detail requests below. All diagrams must be prepared in black ink and should be computer generated, if not, then diagram must be prepared using a straight edge (ruler) and be to SCALE. b. Must accurately depict the entire interior of the location, including placement and number of gaming devices with seating shown, amusement devices, ATMs, merchandise gondolas, tables/booths with ALL seating shown, kitchen, offices, restrooms, bar(s), cash registers, etc., labeled as appropriate. c. Designate the point of primary supervision which provides an unobstructed view of each gaming device. d. Designate any security system cameras, monitors, and mirrors necessary to maintain adequate supervision. e. Provide exact measurements of the distance from the gaming devices to: Cash registers and/or point of supervision The dining area(s) The amusements devices (such as pool tables, arcade game machines) Automated Teller Machines (ATMs) f. g. Indicate the direction each gaming device will face by showing seating. h. Provide the dimensions of the building along the outside walls. i. Note on the diagram in a square block type format: SEE EXAMPLES: http://www.gaming.nv.gov/modules/showdocument.aspx?documentid=2460 http://www.gaming.nv.gov/modules/showdocument.aspx?documentid=2459 20. Provide a minimum of three (3) photographs of your location. The photos must include the front of the establishment, the interior of the establishment (which is representative of the type of business to be operated), and the view from the primary point of supervision to the proposed slot machine area. Identify each photo with the name and address of the establishment, either on the back of each photo or under each