Gaming License Application Form
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1
2Gaming License Application
240 Water Street s s s s Room 108 s s s s Henderson NV s s s s 89015 s s s s 702-565-2045
Applicant:
Doing Business As/At:
Start Date:
Business Phone:
Business Fax:
Gaming Location:
Mailing Address:
Street:
Street:
City, State, Zip:
City, State, Zip:
Type Of Business:
Sole Proprietor
General Partnership
Limited Partnership
Limited Liability Company
Corporation
List the names of all persons having an interest in this business either as a sole owner, partner, joint
venture participant, or the main officers of a corporation:
Name:
Title:
Social Security Number
Home Phone Number
Home Address:
City:
State:
Zip:
Name:
Title:
Social Security Number
Home Phone Number
Home Address:
City:
State:
Zip:
Name:
Title:
Social Security Number
Home Phone Number
Home Address:
City:
State:
Zip:
ALL NAMES LISTED ON THIS APPLICATION MUST BE PROCESSED BY THE
CITY OF HENDERSON, POLICE DEPARTMENT
Premises Owner:
Address:
City, State and Zip
Type Of Gaming Agreement:
Space Lease
Participation Agreement
Owner/Operator
Space Lease/Participation Agreement With:
Type Of License Applied For:
Restricted
Non-Restricted
Slot Route Operator
Description Of Gaming Types/Devices
Number Of Machines:
Number Of Live Games:
Bingo
Race Book
Check all that apply:
Keno
Sports Pool
State Gaming Approval Status:
Approved _________________________
Pending
Date
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Parent category: Business