Personal History Form - Suitability Application

PL125 - Revised 06/28/2017

Page 1 of 19

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. 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.

Required Items:

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.

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

To schedule an appointment call (702) 229-1840

TTY: 7-1-1

CITY OF LAS VEGAS

DEPARTMENT OF COMMUNITY DEVELOPMENT

BUSINESS LICENSING DIVISION

INITIAL

Print Form

PL125 - Revised 06/28/2017

Page 2 of 19

Personal History Form

Date form completed

Zip/Postal Code

State/Province

City/TownApt. #Mailing Address

MiddleFirstName: Last

Zip/Postal CodeState/ProvinceCity/Town

Suite#

Present Business Address

Zip/Postal CodeState/ProvinceCity/TownApt. #Home Address

WeightHeightHair Color

Eye Color

Sex

E-Mail ContactSocial Security NumberDate of Birth

Cell/Mobile Telephone Number

Present Business Telephone NumberHome Telephone Number

If yes, list the additional names below and specify dates of use for each (include maiden

name, aliases, nicknames, American name, other name changes, legal or otherwise)

Yes No

1. Have you ever been known by any other name or names?

2. Place of Birth

If yes, please attach a copy of your Birth Certificate, Certificate of Citizenship or Naturalization Certificate.

If Permanent Resident Alien, please complete section below and attach copy of Permanent Resident Alien Card.

Yes

3. Are you a US Citizen?

ATTACH A COPY OF ALIEN REGISTRATION/

NATURALIZATION

Of what country are you a citizen?

Date of EntryPort of Entry

If Permanent Resident Alien, list number

If yes, please fill out the table below:

Yes No

4. Have you ever been issued a passport?

Passport Number Country of Issue Place Issued Date Issued Expiration Date

INITIAL

PL125 - Revised 06/28/2017

Page 3 of 19

5a. Provide the following information regarding your current marriage and spouse:

Married/Civil Union

Single

Divorced

Engaged

Legally Separated

Widow/Widower

If married, please complete question 5a.

5. What is your current marital status?

Name of Spouse Current Address Telephone Number Spouse's Occupation

Social Security Number Date of Birth Place of Birth Date of Marriage Where Married

6a. How many times have you been married?

Yes No

6. Do you have any previous marriages?

INITIAL

Name of Former Spouse Present Address and Phone Date of Birth

Date and Place of Marriage

Date and Location of Annulment,

Separation or Divorce

Docket/Case # of

Divorce Action

Name of Former Spouse Present Address and Phone Date of Birth

Date and Place of Marriage

Date and Location of Annulment,

Separation or Divorce

Docket/Case # of

Divorce Action

Name of Former Spouse Present Address and Phone Date of Birth

Date and Place of Marriage

Date and Location of Annulment,

Separation or Divorce

Docket/Case # of

Divorce Action

PL125 - Revised 06/28/2017

Page 4 of 19

Name Relation

Living/

Deceased

Date of Birth Current Address Phone Number Occupation

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

If deceased, please note.

INITIAL

Name Date of Birth Birthplace Current Address Supported By

7a. How many children do you have?

Yes No

7. Do you have any children?

PL125 - Revised 06/28/2017

Page 5 of 19

Yes No

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

Name

(include Maiden)

Relation Date of Birth Current Address Phone Number Occupation

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.

Date - From/To Address City/Town County State/Province Country

Zip/Postal

Code

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.

Dates - From/To

Name and Address of School, Training

Program, etc.

Description of Education

Program

List any Degree or

Certification Attained

Graduated

INITIAL

PL125 - Revised 06/28/2017

Page 6 of 19

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.

Dates - From/To Employer Name and Mailing Address

Employer Phone

Number

Name of

Supervisor

Reason for Leaving

Salary Job Title/Classification Description of Duties

Dates - From/To Employer Name and Mailing Address

Employer Phone

Number

Name of

Supervisor

Reason for Leaving

Salary Job Title/Classification Description of Duties

Dates - From/To Employer Name and Mailing Address

Employer Phone

Number

Name of

Supervisor

Reason for Leaving

Salary Job Title/Classification Description of Duties

Dates - From/To Employer Name and Mailing Address

Employer Phone

Number

Name of

Supervisor

Reason for Leaving

Salary Job Title/Classification Description of Duties

Dates - From/To Employer Name and Mailing Address

Employer Phone

Number

Name of

Supervisor

Reason for Leaving

Salary Job Title/Classification Description of Duties

INITIAL

PL125 - Revised 06/28/2017

Page 7 of 19

Yes No

12a. Were you ever discharged, suspended, or asked to resign from employment?

With regard to the previously listed employment:

Date of Discharge,

Suspension, Resignation or

Disciplinary Action

Name and Address of Employer

Name of

Supervisor

Reason for Discharge, Suspension,

Resignation or Disciplinary Action

Yes No

12b. Were you ever charged with any infraction in relation to any employment which was

the subject of any disciplinary action?

With regard to the previously listed employment:

Date of Discharge,

Suspension, Resignation or

Disciplinary Action

Name and Address of Employer

Name of

Supervisor

Reason for Discharge, Suspension,

Resignation or Disciplinary Action

Reference One

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.

Business Address/ Employer AddressAddress

Years knownOccupationTelephone No.Name

Reference Three

Business Address/ Employer AddressAddress

Years knownOccupationTelephone No.Name

Reference Two

Business Address/ Employer AddressAddress

Years knownOccupationTelephone No.Name

INITIAL

PL125 - Revised 06/28/2017

Page 8 of 19

Highest Rank HeldService Serial #Branch of ServiceCountry of Service

Yes No

14. Have you ever served in a military organization of any country or have

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

14a. Have you been tried by military court-martial or have you had any charges filed against you while in the military?

This means any charges filed against you under article 15 of the Uniform Code of Military Justice (Summary Court,

Deck Court, Captain's Mast, Company Punishment, etc.)

Yes No

Attach a copy of your DD214. If that is unavailable, attach a copy of the appropriate branch of the military requesting a copy of your DD214. If

in reserves, attach a copy of your discharge papers. If your military service was in another country, you should provide a copy of whatever

official documentation was provided to you at the time of your discharge.

Type of Discharge(s)Date of Each Discharge/SeparationPeriod(s) of Active Service: From/To

Nature of Charge or

Arrest

Date and Location of

Charge or Arrest

Name of Military

Organization that

filed charges

Disposition (Convicted,

Acquitted, Dismissed,

Pleading, etc.)

Sentence

Yes No

15. Have you ever been arrested or issued a citation in any jurisdiction (excluding traffic

tickets such as speeding)?

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.

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.

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:

Nature of Charge or

Offense/Location where

Incident Occured

Date of Charge or Offense

Name and address of Law

Enforcement Agency or

Court Involved

Disposition (Convicted,

Acquitted, Dismissed,

Pending, Pardoned, etc.)

Sentence

INITIAL

PL125 - Revised 06/28/2017

Page 9 of 19

Nature of Charge or

Offense/Location where

Incident Occured

Date of Charge or Offense

Name and address of Law

Enforcement Agency or

Court Involved

Disposition (Convicted,

Acquitted, Dismissed,

Pending, Pardoned, etc.)

Sentence

Yes No

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

Licensing Agency, Grand Jury, Federal Board, or Commission for any reason whatsoever?

Name of Licensing Agency/or

Commission

Date(s) of Appearance(s) Nature of Hearing Was Testimony Given?

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

jurisdiction below:

Date Last Issued License Number Type of License

Jurisdiction

Issuing License

Expiration Date

of License

Yes No

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

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.

Name on License Type of License Date - From/To

Name and Address of Licensing

Agency/Organization

Disposition of the

Application

INITIAL

PL125 - Revised 06/28/2017

Page 10 of 19

Yes No

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,

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.

Name & Address of Licensing Agency/

Organization (including Country, State/

Province, County or Municipality or Town

Type of License, Permit,

Approval, or Registration

Date of Application

Disposition (Granted,

Denied, or Pending,

etc.)

License, Permit,

Approval or

Registration Number

Yes No

20. Have any of the licenses, permits, or certifications applied for or held by you as identified in the previous

questions ever been denied, suspended, revoked or subject to any conditions in any jurisdictions?

Type of License, Permit, or

Certificate

Name & Address of Governmental

Agency/Organization

Date of Denial, Suspension,

Revocation or Condition

Reason(s) for Denial, Suspension, or

Revocation

Yes No

21. Have you ever held a financial interest in a gambling venture, including race track, race horse, or race dog,

lottery, casino, bookmaking operation, or pari-mutual outside the State of Nevada?

Yes No

22. Have you ever been cited or charged with, or formally accused of, any violation of a statute,

regulation, or code of any local, state, county, municipal, provincial, federal or national government

other than a criminal, disorderly persons, petty disorderly person, or motor vehicle violation?

Governmental Agency/Organization Nature of Charge Date Disposition

INITIAL

PL125 - Revised 06/28/2017

Page 11 of 19

Yes No

23. Have you ever had a warrant for your arrest, failure to appear or summons for anything,

including traffic?

Governmental Agency/Organization Nature of Charge Date Disposition

Yes No

24. Have you ever been barred, trespassed, or otherwise excluded, for any reason other than for the denial,

suspension or revocation of a license or registration from any form or type of casino or gaming/gambling

related operation in any jurisdiction? Check "Yes" even if the disbarment or exclusion is no longer in effect or has

been lifted.

Gaming/Gambling Agency Date of Exclusion Reason for Exclusion

Yes No

25. Have you (as an individual, member of a partnership, or owner, director or officer of a corporation) or your spouse

been party to a lawsuit, either as a plaintiff or defendant? This includes matrimonial matters, negligence matters,

auto accident matters, contract matters, collection matters, debt matters, bank matters, bankruptcies, etc.

Date Filed Name & Address of Court

Docket/Case

Number

Other Parties to Suit

Nature of Suit Disposition Date of Disposition

Date Filed Name & Address of Court

Docket/Case

Number

Other Parties to Suit

Nature of Suit Disposition Date of Disposition

INITIAL

PL125 - Revised 06/28/2017

Page 12 of 19

Yes No

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

Business Name Business Address Date

Status (open, sold,

bankrupt, other)

Type of Business

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

corporation in any jurisdiction?

Nature of Lien/Debt When Filed Where Filed Current Status

ATTACH COPY OF DISCHARGE

Yes No

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

bankruptcy, insolvency or liquidation under any bankruptcy or insolvency law in any jurisdiction?

Date FIled Docket/Case Number Name and Address of Court

Name and Address of

Filing Party

Name and Address of

Trustee

INITIAL

PL125 - Revised 06/28/2017

Page 13 of 19

ATTACH COPY OF PARTICIPATION AGREEMENT

Yes No

29. Will you have any type of slot machines/gaming devices in your establishment that are not owned by you?

Name Address Telephone No. Contact Person Date of Agreement

Provide details below

Yes No

32. Is entertainment to be used in this establishment?

State position/reason below

Yes No

31. Do you intend to actively participate in the operation of this business for which this license is desired?

Provide details below

Yes No

30. Are you currently indebted to a gaming establishment?

Yes No

33. Did another individual complete this application on your behalf?

Provide details below

Name Date of Birth Social Security No. Address Telephone No.

33a. Explain affiliation of this individual and reason this application was completed on your behalf (i.e. language, legal, etc.)

INITIAL

PL125 - Revised 06/28/2017

Page 14 of 19

Question #29 - ATTACH COPY OF PARTICIPATION AGREEMENT

Question #28 - ATTACH COPY OF DISCHARGE

Question #14 - Attach a copy of your DD214. If that is unavailable, attach a copy of the appropriate branch of the military requesting a

copy of your DD214. If in reserves, attach a copy of your discharge papers. If your military service was in another country, you should

provide a copy of whatever official documentation was provided to you at the time of your discharge.

Question #3 - ATTACH A COPY OF ALIEN REGISTRATION/NATURALIZATION

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.

DOCUMENT ATTACHMENT - REVIEW SECTION

INITIAL

PL125 - Revised 06/28/2017

Page 15 of 19

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.

ordinance, and will abide by it in its entirety

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 and read and undertand the Las Vegas Municipal Code,

STATEMENT OF TRUTH AND ACKNOWLEDGMENTS

Signature of Notarial Officer

Signature of Applicant

State of _____________________________________

County of ___________________________________

Signed and Sworn to or Affirmed to

before me this_____________________________day

of__________________________________, 20____by

PL125 - Revised 06/28/2017

Page 16 of 19

NOTE: All items must be initialed

FROM: LAS VEGAS METROPOLITAN POLICE DEPARTMENT

APPLICANTS NAME:______________________________________________________________________

AUTHORIZATION TO RELEASE INFORMATION

LAS VEGAS METROPOLITAN POLICE DEPARTMENT

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.

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.

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.

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.

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.

(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

appropriate location on this request.

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:

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.

PL125 - Revised 06/28/2017

Page 17 of 19

Signature

Print Name

In witness whereof, I have executed this request at

Las Vegas, Nevada, on the _________ day of

____________________________, ______________.

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

13.

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

12.

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

original.

11.

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.

10.

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.

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

Date: _____________________________________

Signature of the Las Vegas Metropolitan Police

Department Officer presenting this Request

Signature of Notarial Officer

State of _____________________________________

County of ___________________________________

Signed and Sworn to or Affirmed to

before me this_____________________________day

of__________________________________, 20____by

PL125 - Revised 06/28/2017

Page 18 of 19