Pl125 Form – Fill Out and Use This PDF

Privilege License Application

Part II - Personal History Form - Suitability Application

Approved for use by the City of Las Vegas

Business Licensing Division -- Department of Planning

Application Instructions:

PLEASE READ ALL INSTRUCTIONS CAREFULLY BEFORE COMPLETING APPLICATION

NOTE: ALL SUBMITTED FORMS BECOME THE PROPERTY OF THE LAS VEGAS METROPOLITIAN POLICE DEPARTMENT

1.This is an interactive on-line form. It is designed to be filled out on-line and printed once completed. If you choose to print a blank form and hand write the answers, click the top box on the first page of the application to expand the form. All hand written answers must be in black ink and in block lettering. Illegible applications WILL NOT be accepted.

2.Saving this document. The SAVE feature has been activated for this form. You may save the form to your computer at any time using Adobe Reader/Acrobat. Please DO NOT SUBMIT THIS FORM ELECTRONICALLY; this document contains sensitive personal information and is not designed to be secure via e-mail transmission.

3.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.

4.Read each question carefully prior to answering. Answer every question completely. Do not leave blank spaces. If a question does not apply to you indicate “Does Not Apply.” If there is nothing to disclose indicate “None.” 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.Signatures and initials must be made in black ink.

6.If the space available is insufficient to respond to a question, you are to supply the required information on an attachment page and clearly identify which question you are answering.

7.Additional information may be required by the City of Las Vegas Business Licensing or the Metro Police investigator. Failure to provide the requested documents in a timely manner could result in denial of your application.

8.Once you application is accepted, it becomes the property of the Las Vegas Metropolitan Police Department. It will not be returned and the LVMPD does not make copies of any documents relating to the application. The applicant is advised to make copies before submitting the application.

9.IT IS THE RESPONSIBILITY OF EACH APPLICANT FOR A LICENSE TO THOROUGHLY FAMILIARIZE HIMSELF/HERSELF WITH ALL APPLICABLE ORDINANCS, RULES AND REGULATIONS PERTAINING TO THE PARTICULAR LICENSE APPLIED FOR.

BE SURE TO.

A.Attach a recent (within the past 6 months) passport size color photograph of yourself.

B.Sign and notarize all applicable forms and pages.

C.Initial each page.

D.Include all required attachments.

E.Retain a copy of the application for your records.

F.Read, initial and sign TWO(2) copies of the Authorization to Release Information.

G.Provide a copy of your driver's license or state issued identification card.

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Personal History Form

Date form completed

Mailing Address (number and street)	Apt. #	City/Town	State/Province	Zip/Postal Code
Home Address (if different from mailing address)	Apt. #	City/Town	State/Province	Zip/Postal Code
Present Business Address (number and street)	Suite#	City/Town	State/Province	Zip/Postal Code

Home Telephone Number			Present Business Telephone Number			Cell/Mobile Telephone Number
Date of Birth			Social Security Number			E-Mail Contact
Sex	Eye Color	Hair Color		Height		Weight
1. Have you ever been known by any other name or names?				Yes	No
2. Place of Birth

3. Are you a US Citizen?	Yes	No		If yes, please attach a copy of your Birth Certificate
4. Have you ever been issued a passport?				Yes	No
5. What is your current marital status?
Married/Civil Union	Single		Divorced		Engaged	Legally Separated	Widow/Widower
6. Do you have any previous marriages?				Yes	No
7. Do you have any children?	Yes			No

8.List names, residence address, dates of birth and most recent occupations of parents, parents-in-law or legal guardian. If deceased, please note.

9. Do you have any brothers, sisters, and do they have respective spouses?

Yes

No

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10.Beginning with your current residence(s) and working backward, provide the following information with respect to each place where you have lived for the past 10 years (including residences while attending college or while in military service). You do NOT need to list any addresses prior to age 18.

11.Beginning with secondary school (high school,) provide the information below with respect to each school, college, graduate, or post graduate school you have attended.

12.Beginning with your present job and working backward, provide the following information in regards to each place you have worked for the past 10 years. You do NOT need to list any information prior to age 18. Include all part-time and full-time employment and military service. Give dates of any unemployment between jobs in proper sequence. You may also attach a copy of your "Work History" form that is available from the Social Security Administration detailing your employment history. If you choose this option, you must still provide the required information referenced in Question 12 either on this form or an attachment.

With regard to the previously listed employment:

12a. Were you ever discharged, suspended, or asked to resign from employment?	Yes	No

With regard to the previously listed employment:

12b. Were you ever charged with any infraction in relation to any employment which was	Yes	No
the subject of any disciplinary action?

13.Provide the names and other information requested of three (3) references over the age of 18 who have known you for at least three (3) years and can attest to your good character and reputation. No person can be a reference who is a member of your family (ie spouse, parents, grandparents, children, grandchildren, siblings, uncles, aunts, nephews, nieces, fathers-in-law, mothers-in-law, sons-in-law, daughters-in-law, brothers-in-law and sisters-in-law, whether by whole or half blood, by marriage, adoption or natural relationship.) No person can be a reference who is a current employer, employee or business associate.

Reference One

Name	Telephone No.	Occupation	Years known
Address		Business Address

Reference Two

Name	Telephone No.	Occupation	Years known
Address		Business Address

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Reference Three

Name	Telephone No.	Occupation		Years known
Address		Business Address
14. Have you ever served in a military organization of any country or have			Yes	No

you been an active or inactive member of a reserve force of any country?

The next question asks about arrests, charges or offenses you may have committed. Prior to answering this question, carefully review the definitions and instructions which follow:

For purposes of the question:

"ARRESTS" include any detaining, holding, or taking into custody by any police or ther law enforcement authorities to answer for the alleged performance of any "offense"

"CHARGE" includes any indictment, complaint, information, summons, or other notice of the alleged commission of any "offense"

"OFFENSE" is all crimes to include: felonies, gross misdemeanors, disorderly persons offenses, petty disorderly offenses, driving while intoxicated/ impaired motor vehicle offenses and violations of probations or any other court order.

"CITATION" is an official summons to appear.

Instructions: Answer "yes" and provide all information to the best of your ability even if:

You did not commit the offense charged.

The charges were dismissed or subsequently downgraded to a lesser charge.

You completed a pretrial intervention or equivalent diversionary program in other jurisdictions.

You were not convicted.

You did not serve any time in prison or jail.

The charges or offenses happened a long time ago.

	15. Have you ever been arrested or issued a citation, excluding traffic related offenses	Yes	No
	such as speeding, in any jurisdiction?

16. Have you ever been called to testify, or otherwise participated in a hearing or proceeding, before any

17.List all current motor vehicle drivers licenses (automobiles, motorcycles, airplanes, boats, recreational vehicles, etc) issued to you in any jurisdiction below:

	18. Have you ever made application for, or held, any professional or occupational license, permit, or certification
	in any jurisdiction, including, but not limited to the following: Real Estate Broker or Salesman, Accountant,
	Attorney, Medical, Boxing Promoter, Manager or Matchmaker, Race Horse Owner, Trainer, Manager, Jockey, Race	Yes	No
	Dog Owner, Securities Dealer, Contractor, Pilot, Insurance, or any other type of professional license? Do NOT
	include Alcoholic Beverage or Driver's License You must answer "Yes" to this question if you ever applied and your
	application was granted, denied, returned to you by the licensing agency for any reason, withdrawn, or is currently pending.

19.Have you made application for or held a license, permit, registration, finding of suitability, qualification, or other authorization to participate in any form or type of casino, gaming/gambling related operation, any

	manufacturer of gaming/gambling equipment, junket operation, horse racing, dog racing, pari-mutual operation,		Yes	No
	lottery, sports betting, internet gaming, etc., or alcoholic beverage operation in any jurisdiction? You must answer
	"Yes" to this question if you ever applied and your application was granted, denied, returned to you by the agency for any reason,
	withdrawn, or is currently pending.
	20. Have any of the licenses, permits, or certifications applied for or held by you as identified in the previous	Yes	No
	questions ever been denied, suspended, revoked or subject to any conditions in any jurisdictions?

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26. Have you ever owned or do you currently own a business either as a full owner or part-owner?

Yes

No

27. Have any individual, local, city, county, state, federal or any other governmental liens/debts been

filed against you as an individual, sole proprietor, member of a partnership, or owner of a Yes No corporation in any jurisdiction?

28. Have you, as an individual, or any business entity in which you have been involved with filed any type of

29. Will you have any type of slot machines/gaming devices in your establishment that are not owned by you?			Yes	No
30. Are you currently indebted to a gaming establishment?	Yes	No
31. Do you intend to actively participate in the operation of this business for which this license is desired?			Yes	No
State position/reason below

32. Is entertainment to be used in this establishment?	Yes	No
33. Did another individual complete this application on your behalf?		Yes	No

DOCUMENT ATTACHMENT - REVIEW SECTION

Below is a listing of all additional documents that need to be attached/included with the submittal of this application. This list is based upon your answers to the previous questions in this document. This list is not all-inclusive as staff may request additional documents for submittal on a case-by-case basis.

Question #28 - ATTACH COPY OF DISCHARGE

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STATEMENT OF TRUTH AND ACKNOWLEDGMENTS

I, ____________________________________, being duly sworn, say that I have read the foregoing License Application,

Suitability Application and financial representation and know the contents thereof, and that the same are true; that the same contains a full and true account of the information requested; and that I executed the same freely and voluntarily and for the uses and purposes therein mentioned, and with the full knowledge that misrepresentation or failure to reveal information request may be deemed sufficient evidence for refusal to issue, revocation of, the license applied for an should license applied for be granted, will abide by all city, county, state and federal laws, and fully understand that failure to do so may result in revocation proceedings.

Further, I attest that:

1.I am the applicant who is submitting this application form.

2.I personally supplied the information contained in this form.

3.I understand and read the English language or I have had an interpreter read, explain and record the answer to each and every question on this application form.

4.Any document accompanying this form that is not an original document is a certified copy of the original document.

5.I swear (or affirm) that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are willfully false, or misleading they will be documented and could result in denial of suitability for licensing.

6.I understand that in case this application is withdrawn or denied, there shall be no refund of any investigation fees paid.

7.I agree to provide and disclose any information that reasonably relates to this application, the applicants qualifications, acceptability or fitness for an approval for suitability or for the requested license.

8.I agree to be fingerprinted and photographed.

I do hereby agree that the City of Las Vegas may obtain information from my past and present employers, criminal justice agencies, financial institutions, Federal, State and local government agencies and other persons and entities and agree to release such information to the City of Las Vegas for use in connection with this application.

I do, for myself, my heirs, executors, administrators, successors and assigns, hereby release, remise and forever discharge the City of Las Vegas, and its agents and employees from any and all manner of actions, claims and demands whatsoever, known or unknown, in all or equity, which I ever had, now have, may have to claim to have against the City of Las Vegas, or its agents or employees, arising out of its use of the information provided in this application or discovered during any investigation thereof.

I do hereby certify that I have read and understand the______________________________________________________

ordinance, and will abide by it in its entirety or any amendments thereto, and furthermore certify that, if this application is approved and a license issued, it will be accepted by me, subject to the terms and provisions of the applicable ordinance and such other rules and regulations as may be, at any time hereafter, adopted or enacted be resolution or ordinance of the licensing authority; and I acknowledge the power of authority of the licensing authorities or other authorized representative to enter any store or business establishment wherein the licensed business or operation is being conducted at any time during business hours, for the purpose of ascertaining compliance with the applicable ordinance, examination of its books of account, or to determine the true parties of interest, including any person(s) having an ownership interest in the licensed premises, or person(s) who may have loaned or otherwise advanced monies for the operation and conduct of such business.

State of _____________________________________

County of ___________________________________

Signature of Applicant

Signed and Sworn to or Affirmed to

before me this_____________________________day

of__________________________________, 20____by

Signature of Notarial Officer

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LAS VEGAS METROPOLITAN POLICE DEPARTMENT

AUTHORIZATION TO RELEASE INFORMATION

APPLICANTS NAME: __________________________________________________________________________

FROM: LAS VEGAS METROPOLITAN POLICE DEPARTMENT

NOTE: ALL ITEMS MUST BE INITIALED

1.I understand that I am applying for a privileged license, permit or work card from the city of Las Vegas/Clark County, Nevada and acknowledge that the burden of proving my qualifications for such a privilege is at all times upon me. I further understand that a full investigation will be made of my background, character and financial responsibility by the Las Vegas Metropolitan Police Department as agent of and for use by the city of Las Vegas/Clark County and I accept any risk of adverse public notice, embarrassment, criticism or financial loss which may result from action with respect to my application. This authorization and request is given freely and without duress, voluntarily waiving any protection against unauthorized disclosure of information under the Privacy Act and other similar legal provisions.

2.I hereby authorize and request all persons to whom this request is presented, having information relating to or concerning me, to furnish such information to a duly appointed officer of the Las Vegas Metropolitan Police Department, whether or not such information would otherwise be protected from disclosure by any constitutional, statutory or common law privilege.

3.I hereby authorize and request all persons to whom this request is presented, having documents relating to or concerning me, to permit a duly appointed officer of the Las Vegas Metropolitan Police Department to review and copy any such documents, whether or not such documents would otherwise be protected from disclosure by any constitutional, statutory or common law privilege.

4.If the person to whom this request is presented is a brokerage firm, bank, savings and loan or other financial institution, or an officer of the same, I hereby authorize and request that a duly appointed officer of the Las Vegas Metropolitan Police Department be permitted to review and obtain copies of any and all documents, records or correspondence pertaining to me, including, but not limited to, past loan information, notes co-signed by me, checking account records, savings deposit records, safe deposit records, passbook records, and general ledger folio sheets. Such information showing the applicant's finances, net worth, or revenues which is submitted as a part of the application for an approval for suitability, as it relates to the above listed suitability investigation.

5.If the person to whom this request is presented is a criminal justice agency or repository of records of criminal history whether within or without the State of Nevada, I hereby authorize and request that a duly appointed officer of the Las Vegas Metropolitan Police Department be permitted to review and obtain copies of any and all documents, records, investigations, photographs or other information pertaining to me, including but not limited to arrests, charges, convictions, dispositions, investigative and intelligence information, records of licensing and work permit agencies including the gaming control board of the State of Nevada and records of parole and pardon agencies.

6.I do hereby make, constitute and appoint any duly appointed officer of the Las Vegas Metropolitan Police Department my true and lawful attorney in fact for me in my name, place and stead, and on my behalf and for use and benefit:

(a)to request, review, copy, sign for otherwise act for investigative purposes with respect to documents and information in the possession of the person to whom this request is presented as I might or could do if personally presented:

(b)to name the person or entity to whom this request is presented and insert that person's name in the appropriate location on this request; and

(c)to place the name of the Las Vegas Metropolitan Police Department officer presenting this request in the appropriate location on this request.

7.I grant to said attorney in fact full power and authority to do, take and perform all and every act and thing whatsoever requisite, proper or necessary to be done in the exercise of any of the rights and powers herein granted, as fully to all intents and purposes as I might or could do if personally present, with full power of substitution or revocation, hereby ratifying and confirming all that said attorney in fact, or his substitute or substitutes, shall lawfully do or cause to be done by virtue of this power of attorney and the rights and powers herein granted.

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8.This power of attorney ends eighteen months from the date of execution.

9.I do, for myself, my heirs, executors, administrators, successors, and assigns, hereby release, remise and forever discharge the person to whom this request is presented, and his agents and employees, from any and all manner of actions, claims and demands whatsoever, known or unknown, in all or equity, which I ever had, now have, may have to claim to have against the person to whom this request is presented, or his agents or employees, arising out of or by reason of complying with this request.

10.I do, for myself, my heirs, executors, administrators, successors, and assigns, hereby release, remise and forever discharge the Las Vegas Metropolitan Police Department, and its agents and employees, from any and all manner of actions, claims and demands whatsoever, known or unknown, in all or equity, which I ever had, now have, may have to claim to have against the Las Vegas Metropolitan Police Department, or its agents or employees, arising out of or by reason of complying with this request.

11.A reproduction of this request by the xerox or similar process shall be for all intents and purposes as valid as the original.

12.I understand that falsifying my application is a Gross Misdemeanor (NRS 199.210).

13.I acknowledge that I have read the foregoing and understand the content and import thereof.

In witness whereof, I have executed this request at Las Vegas, Nevada, on the _________ day of

____________________________, ______________.

Print Name

Signature

State of _____________________________________

County of ___________________________________

Signed and Sworn to or Affirmed to

before me this_____________________________day

of__________________________________, 20____by

Signature of Notarial Officer

Signature of the Las Vegas Metropolitan Police

Department Officer presenting this Request

Date: _____________________________________

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LAS VEGAS METROPOLITAN POLICE DEPARTMENT

AUTHORIZATION TO RELEASE INFORMATION

APPLICANTS NAME: __________________________________________________________________________

FROM: LAS VEGAS METROPOLITAN POLICE DEPARTMENT

NOTE: ALL ITEMS MUST BE INITIALED

1.I understand that I am applying for a privileged license, permit or work card from the city of Las Vegas/Clark County, Nevada and acknowledge that the burden of proving my qualifications for such a privilege is at all times upon me. I further understand that a full investigation will be made of my background, character and financial responsibility by the Las Vegas Metropolitan Police Department as agent of and for use by the city of Las Vegas/Clark County and I accept any risk of adverse public notice, embarrassment, criticism or financial loss which may result from action with respect to my application. This authorization and request is given freely and without duress, voluntarily waiving any protection against unauthorized disclosure of information under the Privacy Act and other similar legal provisions.

2.I hereby authorize and request all persons to whom this request is presented, having information relating to or concerning me, to furnish such information to a duly appointed officer of the Las Vegas Metropolitan Police Department, whether or not such information would otherwise be protected from disclosure by any constitutional, statutory or common law privilege.

3.I hereby authorize and request all persons to whom this request is presented, having documents relating to or concerning me, to permit a duly appointed officer of the Las Vegas Metropolitan Police Department to review and copy any such documents, whether or not such documents would otherwise be protected from disclosure by any constitutional, statutory or common law privilege.

4.If the person to whom this request is presented is a brokerage firm, bank, savings and loan or other financial institution, or an officer of the same, I hereby authorize and request that a duly appointed officer of the Las Vegas Metropolitan Police Department be permitted to review and obtain copies of any and all documents, records or correspondence pertaining to me, including, but not limited to, past loan information, notes co-signed by me, checking account records, savings deposit records, safe deposit records, passbook records, and general ledger folio sheets. Such information showing the applicant's finances, net worth, or revenues which is submitted as a part of the application for an approval for suitability, as it relates to the above listed suitability investigation.

5.If the person to whom this request is presented is a criminal justice agency or repository of records of criminal history whether within or without the State of Nevada, I hereby authorize and request that a duly appointed officer of the Las Vegas Metropolitan Police Department be permitted to review and obtain copies of any and all documents, records, investigations, photographs or other information pertaining to me, including but not limited to arrests, charges, convictions, dispositions, investigative and intelligence information, records of licensing and work permit agencies including the gaming control board of the State of Nevada and records of parole and pardon agencies.

6.I do hereby make, constitute and appoint any duly appointed officer of the Las Vegas Metropolitan Police Department my true and lawful attorney in fact for me in my name, place and stead, and on my behalf and for use and benefit:

(a)to request, review, copy, sign for otherwise act for investigative purposes with respect to documents and information in the possession of the person to whom this request is presented as I might or could do if personally presented:

(b)to name the person or entity to whom this request is presented and insert that person's name in the appropriate location on this request; and

(c)to place the name of the Las Vegas Metropolitan Police Department officer presenting this request in the appropriate location on this request.

7.I grant to said attorney in fact full power and authority to do, take and perform all and every act and thing whatsoever requisite, proper or necessary to be done in the exercise of any of the rights and powers herein granted, as fully to all intents and purposes as I might or could do if personally present, with full power of substitution or revocation, hereby ratifying and confirming all that said attorney in fact, or his substitute or substitutes, shall lawfully do or cause to be done by virtue of this power of attorney and the rights and powers herein granted.

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8.This power of attorney ends eighteen months from the date of execution.

9.I do, for myself, my heirs, executors, administrators, successors, and assigns, hereby release, remise and forever discharge the person to whom this request is presented, and his agents and employees, from any and all manner of actions, claims and demands whatsoever, known or unknown, in all or equity, which I ever had, now have, may have to claim to have against the person to whom this request is presented, or his agents or employees, arising out of or by reason of complying with this request.

10.I do, for myself, my heirs, executors, administrators, successors, and assigns, hereby release, remise and forever discharge the Las Vegas Metropolitan Police Department, and its agents and employees, from any and all manner of actions, claims and demands whatsoever, known or unknown, in all or equity, which I ever had, now have, may have to claim to have against the Las Vegas Metropolitan Police Department, or its agents or employees, arising out of or by reason of complying with this request.

11.A reproduction of this request by the xerox or similar process shall be for all intents and purposes as valid as the original.

12.I understand that falsifying my application is a Gross Misdemeanor (NRS 199.210).

13.I acknowledge that I have read the foregoing and understand the content and import thereof.

In witness whereof, I have executed this request at Las Vegas, Nevada, on the _________ day of

____________________________, ______________.

Print Name

Signature

State of _____________________________________

County of ___________________________________

Signed and Sworn to or Affirmed to

before me this_____________________________day

of__________________________________, 20____by

Signature of Notarial Officer

Signature of the Las Vegas Metropolitan Police

Department Officer presenting this Request

Date: _____________________________________

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