APPLICATION TO CHANGE OR ADD A CORPORATE OFFICER OF A CORPORATION OR MEMBER / MANAGER OF A LIMITED LIABILITY COMPANY. General Instructions

Transcription

1 NEVADA STATE CONTRACTORS BOARD 2310 Crprate Circle, Suite 200, Hendersn Nevada, (702) Fax (702) Investigatins (702) Kietzke Lane, Suite 102, Ren, Nevada, (775) FAX (775) , Investigatins (775) Website: APPLICATION TO CHANGE OR ADD A CORPORATE OFFICER OF A CORPORATION OR MEMBER / MANAGER OF A LIMITED LIABILITY COMPANY 1. Please type r print in ink when cmpleting this frm. General Instructins 2. Make sure the applicatin is prperly signed by a crprate fficer r managing member. 3. Read all instructins carefully. The Nevada State Cntractrs Bard (Bard) desires t prvide curteus and timely service t all applicants. T maximize its efficiency and the level f service, the Bard will prcess cmplete applicatins nly. A cmplete applicatin includes all applicable supprting dcuments and fees. The Bard will nt act as yur agent in gathering infrmatin r supprting dcuments necessary fr the cnsideratin f this applicatin. Incmplete applicatins will be returned t yu. 4. Cmplete each sectin, and answer all questins n this frm. 5. Attach a cpy f yur crprate minutes r LLC minutes shwing the electin f each new fficer, member r manager. 6. This frm cannt be used t change the qualified persn. If there has been a disassciatin f the qualified persn, yu must ntify the bard in writing, within 10 days (including the date f disassciatin), and file the necessary change applicatin. (The required applicatin frm is available n ur web site: r frm an ffice f the Bard.) 7. Include required fee f $ SECTION 1 BUSINESS NAME; LICENSE NUMBER Business Name: Use the legal business name as it appears n yur license. If there has been a change in yur legal business name, a separate change f name applicatin is required. License Number: This frm can be used fr mre than ne license nly if the licenses are held by the same business entity. Legal Business Name: (Use Name as Set Frth n the License) License Number (s): Phne N.: ( ) Address: Facsimile N.: ( ) FOR OFFICE USE ONLY DO NOT WRITE IN THIS SPACE Date Received: Amunt: Receipt #: File N.: Withdrawn Date: Reasn: Applicatin N.: Apprved: Denied: Transactin Clsed: Date: Entered by: SECTION 2 - BUSINESS ENTITY TYPE This frm can be used t change the crprate fficers f an existing crprate license, r the members and managers with managing authrity f an existing limited liability cmpany license. This frm cannt be used t change the license entity. This applicatin is fr a (check the apprpriate business entity): Crpratin Crpratins may limit the reprting f persnnel changes t: the President, Secretary, Treasurer and any fficer wh has managerial and/r signatry authrity in Nevada r is authrized t legally bind the licensee. Yu must attach a cpy f the crprate minutes shwing the electin f any new fficer r the change f an existing fficer s title. Limited Liability Cmpany Yu must attach a cpy f the minutes fr the electin r appintment f any new members and managers with managing authrity. If any f yur members are legal entities, r if yur LLC has elected fficers, please include an rganizatinal chart identifying the individuals assciated with the member entities. Nevada State Cntractrs Bard Applicatin fr Officer Change / Member Manager Change Revised 9/16 Page 1 f 5

2 SECTION 3 - PERSONNEL Persnnel: Supply the identifying infrmatin belw fr each persn t be added r deleted frm this license. Backgrund Disclsure Statement: Each persn yu are adding t this license must cmplete a backgrund disclsure statement. The required frm is n page 4. Add Delete Change SECTION 4 OWNERSHIP CHANGE Has there been a change in wnership f mre than 50%? N Yes If yes, prvide names and addresses f new wner(s) belw (Print Name) (Percentage f Ownership) (Print Name) (Percentage f Ownership) (Physical Street Address / Mailing Address) (Physical Street Address / Mailing Address) (City, State, Zip Cde) (City, State, Zip Cde) SECTION 5 - AFFIDAVIT AND AUTHORIZED SIGNATURE I am authrized t sign this Affidavit and Release Authrizatin n behalf f the licensee described and identified in this applicatin. T the best f the licensee s / applicant s knwledge, the infrmatin cntained in the applicatin and its supprting dcuments are free f fraud, misrepresentatin, r missin f material fact. T the best f the licensee s / applicant s knwledge, the infrmatin cntained in the applicatin and its supprting dcuments are truthful, crrect, and cmplete; and, disclses all material facts regarding the applicant and assciated individuals necessary t prperly evaluate the applicant s qualificatin fr licensure. The licensee / applicant will ensure that any infrmatin subsequently submitted t the Bard in cnjunctin with this applicatin r its supprting dcuments meets the same standard as set frth abve. The licensee / applicant understands that this applicatin will be classified as a public recrd and will be available fr inspectin by the public, except with regard t the release f infrmatin classified as cnfidential pursuant t NRS The licensee / applicant understands that the Nevada State Cntractrs Bard has the authrity t cnduct apprpriate backgrund investigatins fr the purpse f verifying all statements and facts represented in this applicatin and supprting dcumentatin. Signature Requirements: A principal f the applying cmpany must sign this applicatin. By: (Signature f Crprate Officer r Managing Member) Title: (Print Name) Date: Nevada State Cntractrs Bard Applicatin fr Officer Change / Member Manager Change Revised 3/27/17 Page 2 f 5

3 SECTION 6 BACKGROUND DISCLOSURE (Pages 4-6) Yu MUST include ANY and ALL criminal cnvictins incurred as an individual r as the principal f a crpratin r ther business entity. Failure t disclse a cnvictin is misrepresentatin r missin which vilates NRS (7) and NRS (2). Reprtable ffenses include any f the fllwing, whether yu pled guilty r n cntest, AND regardless f the utcme f the case: Nn-vilent misdemeanr, including DUI, within the past (15) years Misdemeanr crimes invlving vilence against anther persn, fraud r theft Felny cnvictins r felny arrests (even if charges were reduced/dismissed). I understand the Bard utilizes infrmatin frm the Federal Bureau f Investigatins (FBI) and the Nevada Criminal Histry Repsitry t cmpare with the infrmatin I disclse n this applicatin. I am aware that these recrds are likely t include all instances f criminal activity, including thse matters that may have been sealed, expunged, had the charges reduced r dismissed. I understand it is my respnsibility t be hnest abut any such activities that have ccurred in my life and I will err n the side f cautin by including any and all such instances. My applicatin will nt be autmatically denied because f infrmatin btained thrugh the backgrund disclsure and criminal histry verificatin. When reviewing prir criminal cnvictins, the NSCB cnsiders such additinal factrs as the seriusness f the crime, the time that has passed since the cnvictin and any evidence f rehabilitatin the applicant submits. If yu misrepresent, mit r lie n yur applicatin, yur applicatin MAY be denied. If yu have any questins cncerning the disclsure f arrests r cnvictins, please call the Investigatins Department f the NSCB, at in Hendersn r in Ren. FINANCIAL DISCLOSURES Yu MUST disclse any unpaid r unreslved liens, lawsuits, judgments and claims, including tax claims. Yu are advised t btain a cpy f yur credit reprt, Experian recmmended, which will prvide yu with any unpaid, unreslved liens r claims, all lawsuits, and all judgments. Pay particular attentin t any tax claims r liens that have been made r filed against yu. If yu have entered int any repayment r credit cnslidatin agreements, attach cpies f thse agreements t yur applicatin. I HEREBY CERTIFY I HAVE READ THIS NOTICE. NAME: SIGNATURE: Nevada State Cntractrs Bard Applicatin fr Officer Change / Member Manager Change Revised 3/27/17 Page 3 f 5

4 NEVADA STATE CONTRACTORS BOARD APPLICANT BACKGROUND DISCLOSURE STATEMENT AND AUTHORIZATION FOR RELEASE OF INFORMATION BUSINESS NAME: NRS and NRS authrizes the Nevada State Cntractrs Bard (NSCB) t cnduct backgrund investigatins, btain credit reprts, and t request fingerprints fr submissin t the Nevada Highway Patrl (NHP) and the FBI fr a determinatin f identity, fugitive status r prir criminal histry. A separate frm MUST be cmpleted by EACH Principal and Qualified Emplyee ***A COPY OF A VALID DRIVER S LICENSE OR GOVERNMENT ISSUED PHOTO I.D. MUST ACCOMPANY THIS FORM. *** FIRST NAME MIDDLE NAME LAST NAME Fr Bard Staff Only Live Scan Prints Hard Cpy Prints TITLE DATE OF BIRTH PLACE OF BIRTH SOCIAL SECURITY NUMBER OTHER NAME USED, (IF APPLICABLE) SEX RACE HEIGHT WEIGHT HAIR COLOR EYE COLOR RESIDENCE ADDRESS (AND MAILING ADDRESS IF DIFFERENT) CITY STATE ZIP ADDRESS MARRIED (Fr Sle Prprietrs Only) YES / NO 1. Have yu ever, as an individual r principal f a crpratin r ther business entity, been cnvicted f, r pled guilty r n cntest t a felny crime? N Yes Yu must cmplete a criminal disclsure statement fr EACH incident. 2. Have yu ever, as an individual r principal f a crpratin r ther business entity, been cnvicted f, pled guilty, r n cntest t any misdemeanr crime? (Limit t misdemeanr cnvictins within the last 15 years, UNLESS the crime invlved vilence against anther persn, fraud r theft). N Yes Yu must cmplete a criminal disclsure statement fr EACH incident. 3. Are there currently criminal charges pending against yu? N Yes Attach a detailed explanatin, including a cpy f the cmplaint, and/r charging dcument. 4. Within the last 7 years, have yu filed r been adjudicated Bankrupt under yur individual name, a crprate name r any ther business entity name? N Yes Attach a cpy f the discharge dcument. If discharged less than 3 years, attach a cmplete cpy f the prceedings, including a schedule f creditrs listed in the bankruptcy petitin. If the bankruptcy has nt been discharged, include yur plan f rerganizatin and prf f cmpliance. 5. D yu anticipate filing bankruptcy within the next 6 mnths? N Yes 6. Have yu, r any business entities f which yu were a member, partner, fficer, directr, r assciate received any ntice f liens, suits, judgments, r claims (including tax claims) which remain unreslved r unsatisfied OR have yu entered int payment agreements regarding past due taxes r ther debts? N Yes Attach a detailed explanatin. 7. Are there nw any unpaid past due bills fr materials, services rendered, r labr? N Yes Attach a detailed explanatin. 8. Have yu, r any business entities f which yu were a member, partner, fficer, directr, assciate, r qualified emplyee had a cntractr s license denied, suspended, revked, r therwise disciplined BY NEVADA OR ANY OTHER STATE? Are there any disciplinary prceedings currently pending against yu, r any license n which yu have appeared IN NEVADA OR ANY OTHER STATE? N Yes Attach a detailed explanatin including the name f the state in which the license was held, license number, and business name. 9. D yu have a prprietary interest (i.e., wnership, stck, shares) in this applicant? (This questin des nt pertain t sle prprietrs) N Yes Percentage Owned: % 10. Are yu a citizen f the United States f America? N Attach a cpy f INS card and Scial Security Card. Yes Nevada State Cntractrs Bard Applicatin fr Officer Change / Member Manager Change Revised 3/27/17 Page 4 f 5

5 Applicant Backgrund Disclsure Statement Authrizatin fr Release f Infrmatin In rder t cmply with the requirements f Nevada s Department f Public Safety, fingerprint cards and LiveScan fingerprints cannt be accepted until after yu submit yur applicatin and cmpleted Fingerprint Backgrund Waiver frm(s) t the Bard. Once these frms has been submitted t the Nevada State Cntractrs Bard yu may prceed with btaining the required fingerprints. In cnsideratin fr prcessing my applicatin fr a Nevada State Cntractr s License, I, the undersigned whse name and persnal infrmatin vluntarily appear abve, d hereby and irrevcably agree t the fllwing: 1. I hereby authrize the NEVADA STATE CONTRACTORS BOARD (hereinafter BOARD ) t submit a set f my fingerprints t the Nevada Department f Public Safety, Recrds Bureau fr the purpse f accessing and reviewing Nevada and Natinal criminal histry recrds that may pertain t me. In giving this authrizatin, I expressly understand that the infrmatin may include infrmatin pertaining t ntatins f arrest, detainments, indictments, infrmatin r ther charges fr which the final curt dispsitin is pending r is unknwn t the abve referenced agencies. Fr recrds cntaining final curt dispsitin infrmatin, I understand that the release may include infrmatin pertaining t dismissals, acquittals, cnvictins, sentences, crrectinal supervisin infrmatin and infrmatin cncerning the status f my parle r prbatin when applicable. Further, I understand that the infrmatin may include similar infrmatin btained frm ther lcal, state and federal criminal justice agencies and may include infrmatin pertaining t cnvicted persn data, utstanding arrest warrants, missing persns and current and/r prir gaming and nn-gaming sheriff s wrk cards that were issued t me. 2. I understand that I may review and challenge the accuracy f any and all criminal histry recrds which are returned t the BOARD. 3. I hereby release frm liability and prmise t hld harmless under any and all causes f legal actin, the State f Nevada, the Nevada State Cntractrs Bard, its fficer(s), agent(s) and/r emplyee(s) wh cnducted my criminal histry recrds search and prvided infrmatin t the BOARD fr any statement(s), missin(s), r infringement(s) upn my current legal rights. I further release and prmise t hld harmless and cvenant nt t sue any persns, firms, institutins r agencies prviding such infrmatin t the State f Nevada and the BOARD n the basis f their disclsures. I have signed this release vluntarily and f my wn free will. 4. In giving the abve authrizatin, I understand that all infrmatin prvided t the BOARD may be reviewed by the BOARD r any ther emplyee within the BOARD S rganizatin deemed necessary t make an infrmed decisin. This infrmatin is cnfidential, as relating t a third party beynd that f the BOARD and f the criminal justice agencies in the perfrmance f their fficial duties, and may nt be further disseminated. (Please initial) A reprductin f this authrizatin fr release f infrmatin by phtcpy, facsimile r similar prcess, shall fr all purpses be as valid as the riginal. PURSUANT TO NRS , I CERTIFY THAT I HAVE CAREFULLY REVIEWED THE INFORMATION CONTAINED IN THIS DOCUMENT AND I ATTEST TO THE TRUTH AND ACCURACY OF THE INFORMATION CONTAINED IN THIS BACKGROUND DISCLOSURE STATEMENT UNDER PENALTY OF PERJURY. Applicant s Name: (LAST, FIRST MIDDLE) (SIGNATURE) Address: Date: T Be Cmpleted by Bard Staff Only: Submitted by: NEVADA STATE CONTRACTORS BOARD Date Submitted: 2310 CORPORATE DRIVE, SUITE 200 HENDERSON, NEVADA Agency s Representative: (PRINT) (SIGNATURE) Nevada State Cntractrs Bard Applicatin fr Officer Change / Member Manager Change Revised 3/27/17 Page 5 f 5