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"! ! ^ {!"0@" &Y& J&!tvAT D!! @"&T > : STATE OF NEVADA DEPARTMENT OF BUSINESS AND INDUSTRY OFFICE OF LABOR COMMISSIONER 1818 COLLEGE PARKWAY, SUITE 102 CARS0N CITY, NEVADA 89706 775-684-1890 3300 WEST SAHARA AVENUE, SUITE 225 LAS VEGAS, NEVADA 89102 702-486-2650  APPLICATION FOR EMPLOYMENT AGENCY LICENSE All Questions Must be Answered Application Must be Completed in either Blue Ink or be Typewritten Please select the purpose of your application: New  FORMCHECKBOX  Renewed  FORMCHECKBOX  Employment Agency License for the year ending December 31, 20____ LICENSEE BUSINESS NAME AND BUSINESS ADDRESS _________________________________________________________________________ (Agency Name) _________________________________________________________________________ Number Street Suite No. _________________________________________________________________________ City Zip Business Telephone No.___________________________________ E-mail Address___________________________________ The Applicant is (Check Box)  FORMCHECKBOX  Individual  FORMCHECKBOX  Partnership  FORMCHECKBOX  Corporation or association  FORMCHECKBOX  Other (describe)____________ Name and address of Parent Company, if different from business name: _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ What type of employment agency do you intend to conduct? (Check Box)  FORMCHECKBOX  Regular  FORMCHECKBOX  Babysitting  FORMCHECKBOX  Temporary Help APPLICANT INFORMATION *NAC 611.050: A person who submits an application for a license to conduct a private employment agency must have the authority to legally bind the private employment agency. NAC 611.050 (2): If the applicant is not a natural person, a principal who has the authority to legally bind the applicant. Name_____________________________________________ ______________________ _____________________________ Title Home Telephone No. Home Address___________________________________________________________________________________________ Number, Street, Apt. No. City State Zip ----------------------------------------------------------------------------------------------------------------------------------------------------------- Name______________________________________________ _____________________ _____________________________ Title Home Telephone No. Home Address___________________________________________________________________________________________ Number, Street, Apt. No. City State Zip ----------------------------------------------------------------------------------------------------------------------------------------------------------- Name______________________________________________ _____________________ _____________________________ Title Home Telephone No. Home Address___________________________________________________________________________________________ Number, Street, Apt. No. City State Zip Each applicant is required to answer the following questions. Any falsification of this application will be cause for denial or revocation: Applicants Name___________________________________________________________________________________________ Citizen of U.S.? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Drivers License No.___________________________ State __________________________ Expiration Date __________________ Has applicant been arrested (except minor traffic violations)? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If yes, list arrest(s): DateChargeLocationDisposition Does the applicant conduct or intend to conduct any other business? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If yes, list the name, address and telephone number of the other business: Business Name______________________________________________________________Telephone________________________ Business Address_____________________________________________________________________________________________ Has the applicant ever applied for a private employment agency license previously? Yes  FORMCHECKBOX  Date of Application______________________ No  FORMCHECKBOX  Has the applicant ever had a previous private employment agency license revoked or denied? Yes FORMCHECKBOX  No  FORMCHECKBOX  If yes, give an explanation. Use additional sheets of paper if necessary.) Have any complaints been filed against applicant while engaged in the business of a private employment agency or as an employee or counselor of a private employment agency in Nevada or any other state? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If yes, give an explanation. Use additional sheets of paper if necessary.) Has the applicant ever owned or been employed at a private employment agency in Nevada or any other state? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Owner  FORMCHECKBOX  Employee  FORMCHECKBOX  Give the name, address and telephone number of the agency. Agency Name__________________________________________________________Telephone No.__________________________ Address_____________________________________________________________________________________________________ Number, Street, Suite City State Zip The filing of an application does not authorize the applicant to conduct any business for which a license is required, and any carrying on of such business before a license is issued may be grounds for denial of a license. CERTIFICATION I, the undersigned, have answered all questions in this application and to the best of my knowledge, all answers are true and correct. I further understand that disclosure of any false, misleading, or incorrect answers could result in denial or revocation of the license. 45RTXYst     ' ( > ? 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