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NEVADA STATE CONTRACTORS BOARD (Nevada State Contractors Board)

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NEVADA STATE CONTRACTORS BOARD
5390 KIETZKE LANE, SUITE 102, RENO, NEVADA, 89511 (775) 688-1141 FAX (775) 688-1271, INVESTIGATIONS (775) 688-1150
2310 CORPORATE CIRCLE, SUITE 200, HENDERSON, NEVADA, 89074, (702) 486-1100 FAX (702) 486-1190, INVESTIGATIONS (702) 486-1110
Website: www.nscb.nv.gov
Nevada State Contractors Board Revised 2/2020
Application for Conversion of Entity
Page 1 of 9
APPLICATION FOR CONVERSION OF ENTITY
General Instructions
1. Please type or print in ink when completing this form.
2. Make sure the application is properly signed.
3. Read all instructions carefully. The Nevada State Contractors Board (Board) desires to provide courteous and timely service to
all applicants. To maximize its efficiency and the level of service, the Board will process complete applications only. A complete
application includes all applicable supporting documents and fees. The Board will not act as your agent in gathering
information or supporting documents necessary for the consideration of this application. Incomplete applications will be
returned to you.
4. Complete each section, and answer all questions on this form.
5. This form cannot be used to change the qualified person. If there has been a disassociation of the qualified person, you must
notify the Board in writing, within 10 days (including the date of disassociation), and file the necessary change application. (The
required application form is available on our web site, or from an office of the Board.)
6. Include Required Fee of $300.00
SECTION 1 – BUSINESS NAME:
Current Business Name: ______________________________________________________________
(Use Name Currently Shown on Your License)
Email Address: _________________________________
License Number (s): ____________________
Business Name: The legal business name is the name that will appear on the license and is the actual name under which the
contracting business will be conducted. If you will be using a fictitious business name (doing business as), list that name also, and
include a filed copy of your fictitious name certificate.
Legal Business Name of Resulting Entity: ______________________________________________________________________
Nevada Business ID: ___________________________________________
All businesses are required to have a Nevada State Business License which has a unique Nevada Business ID. Contact the Nevada Secretary of State
to obtain a Nevada State Business License. They can be reached at (702) 486-2880 or www.sos.state.nv.us.
SECTION 2 – BUSINESS ENTITY
Nevada Revised Statute, Chapter 92A provides for the conversion of certain entity types when the constituent or resulting entity is a
domestic entity organized and existing under the laws of the State of Nevada. If neither the constituent nor the resulting entity is a
domestic entity organized and existing under the laws of the State of Nevada, see Notice Regarding Conversion of Foreign Entity on
page 2.
You should consult with your legal counsel regarding plans of conversion, and whether or not such action is applicable to
your business.
FOR OFFICE USE ONLY – DO NOT WRITE IN THIS SPACE
Date Received: _____________ Amount: ________________ Receipt #:_________ Data Entry: ___________
Withdrawn: ____________ Approved: ____________ Denied: ___________
Data Entry Change Request: ___________File Closed: ___________
Nevada State Contractors Board Revised 2/2020
Application for Conversion of Entity
Page 2 of 9
Business Entity: Designate the entity type and State of origin for both the constituent and resulting entity by placing a check mark in
the appropriate box and provide the State of origin for both the constituent entity and resulting entity.
CONSTITUENT ENTITY
Corporation – State of Origin
__________
Limited Liability Company – State of Origin
__________
General Partnership – State of Origin
_________
Limited Partnership – State of Origin
_________
RESULTING ENTITY
Corporation – State of Origin __________
Limited Liability Company – State of Origin
__________
Limited Partnership – State of Origin _________
You must attach a copy of the filed Articles of Conversion, along with the certificate of authority issued by the Nevada Secretary of
State. Additional documents required are as follows:
If the resulting entity is a Limited Liability Company: Submit a copy of your Articles of Organization and Operating Agreement.
If the resulting entity is a Limited Partnership: Submit a copy of your partnership agreement.
NOTICE
REGARDING CONVERSION OF FOREIGN ENTITY:
If the resulting entity is not a Nevada business entity, whose
conversion is governed by Nevada Revised Statute, Chapter 92A, you must provide a written legal opinion from your own
legal counsel regarding the authority for conversion. The opinion must cite the statutory authority which provides for the
conversion, and address whether or not the laws governing conversions in that State provide that the resulting entity is a
continuation of the constituent entity, and whether or not the liability of the constituent entity flows to the resulting entity.
SECTION 3 – PERSONNEL OF RESULTING ENTITY
Personnel: Supply the identifying information below for each person (or company if an LLC) to be added or deleted from this license.
Background Disclosure Statement: Each person you are adding to this license must complete a background disclosure statement.
The required form is on page 6. A separate form must be completed for each person.
Add Delete Change
Full Legal Name: ________________________________________ Title: __________________
Full Legal Name: ________________________________________ Title: __________________
Full Legal Name: ________________________________________ Title: __________________
Full Legal Name: ________________________________________ Title: __________________
Full Legal Name: ________________________________________ Title: __________________
Full Legal Name: ________________________________________ Title: __________________
Full Legal Name: ________________________________________ Title: __________________
Full Legal Name: ________________________________________ Title: __________________
Note: Attach a copy of your corporate minutes showing the election or appointment of each officer, member or manager with
managing authority to be added to this license.
If additional space is needed, please attach a separate sheet
Nevada State Contractors Board Revised 2/2020
Application for Conversion of Entity
Page 3 of 9
SECTION 4 - CONTRACTORS LICENSES
Each new person that you are adding to this license must provide a list of Contractors licenses on which they have appeared, whether
in Nevada or any other state. If your response to this section is “none”, or if you are not adding any new personnel, indicate same in the
space below.
Company Name
State
Lic. No.
Issue Date
Current License Status
SECTION 5 - GENERAL QUESTIONS
Answer all questions and attach any supplemental information required. Your answer to each question applies to the constituent and
resulting entities, as well as all personnel listed above in section 3.
1. Since obtaining this license, have you, or any of you, had a contractor’s license denied, suspended or revoked by Nevada or any
other state? Or been connected with any person, firm, partnership or corporation whose contractor’s license was denied,
suspended or revoked by Nevada or any other state?
No Yes - attach a detailed explanation including State, license number, and date.
2. Are there any judgments, suits or claims pending or recorded against you?
No Yes - attach a detailed explanation.
3. Are there any liens or stop notices for labor or materials filed on any of your work anywhere?
No Yes - attach a detailed explanation.
4. Since obtaining this license, have you or any of you, pled “guilty” or “no contest” to, or been convicted of a crime?
No Yes - attach a detailed explanation for each instance, including copies of the original complaint, information, or
indictment and final judgment or conviction for any/ and all arrests.
SECTION 6 - FINANCIAL RESPONSIBILITY
1. Has there been a material change in ownership as a result of the conversion?
No Yes – If yes, provide names and addresses of persons holding at least a 25% interest.
2. Were all of the assets and liabilities of the constituent entity transferred to the resulting entity?
No Yes
3. Financial Statement Requirements: You must submit a current financial statement (statement) with this application that meets
the following criteria.
• Financial statements must be for the resulting entity.
• All statements must be in U.S. dollars.
• Business statements must include a classified balance sheet.
• Personal statements that have been prepared by a Certified Public Accountant must include a supplemental schedule
disclosing working capital and net worth.
Nevada State Contractors Board Revised 02/2020
Application for Conversion of Entity
Page 4 of 9
For License Monetary Limits of $10,000 or less you must provide one of the following:
• A current financial statement prepared by an independent certified public accountant; or
• A current financial statement submitted on a form prescribed by the Board (available on the Board’s website
www.nscb.nv.gov
, click on contractor forms); or
• A current financial statement (Balance Sheet) prepared using accounting software in accordance with generally accepted
accounting principles and accompanied by an affidavit that verifies the accuracy of the financial statement.
*To prevent a delay in the processing of your application, if you are unfamiliar with preparing your own financial
statement, you are encouraged to seek the advice of an Accountant.
Note: Self-prepared or compiled statements must be current to within six months from the date the application is
received.
For License Monetary Limits more than $10,000 but less than $50,000 you must provide one of the following:
• A compiled financial statement prepared by an independent certified public accountant, current within 6 months from the
date the application is received; or
• A reviewed or audited financial statement, prepared by an independent certified public accountant, current within one (1)
year from the date the application is received.
For License Monetary Limits of $50,000 or more but less than $250,000 you must provide one of the following:
• A compiled financial statement with full disclosures, prepared by an independent certified public accountant, current within
6 months from the date the application is received; or
• A reviewed or audited financial statement, prepared by an independent certified public accountant, current within one (1)
year from the date the application is received.
For License Monetary Limits of $250,000 or more: you must provide a financial statement that is prepared and reviewed or
audited by an independent certified public accountant, current within one (1) year from the date the application is received.
4. Bank Verification Form: The bank verification form found on page 11, must be completed by your bank and submitted with your
application.
SECTION 7 – QUALIFIED INDIVIDUAL
Qualified Individual: This form cannot be used to change the qualified person on this license. If there has been a disassociation of the
qualified person, you must notify the board in writing, within 10 days (including the date of disassociation), and file the necessary
change application. (The required application form is available on our web site, or from an office of the Board.) Check the appropriate
box to indicate whether or not the current qualified individual is still associated with the resulting entity, or if they have terminated their
employment or association. All qualified individuals must sign.
The qualified individual(s) currently listed on this license is still an employee, officer, director, manager, or associate of the
resulting entity.
____________________________________ _____________________________________
Signature of qualified person Print Name
____________________________________ _____________________________________
Signature of qualified person Print Name
The qualified individual currently listed on this license terminated their employment or association with this licensee effective
on the following date: _____________________.
SECTION 8 - BOND RIDER
If your license currently maintains a surety bond, attach an original rider from your surety company amending the name on your bond to
the Resulting Entity name.
Nevada State Contractors Board Revised 2/2020
Application for Conversion of Entity
Page 5 of 9
SECTION 9 - AFFIDAVIT AND AUTHORIZED SIGNATURE
I am authorized to sign this Affidavit and Release Authorization on behalf of the licensee described and identified in this application.
To the best of the licensee’s / applicant’s knowledge, the information contained in the application and its supporting documents are free
of fraud, misrepresentation, or omission of material fact. To the best of the licensee’s / applicant’s knowledge, the information
contained in the application and its supporting documents are truthful, correct, and complete; and, discloses all material facts regarding
the applicant and associated individuals necessary to properly evaluate the applicant’s qualification for licensure.
The licensee / applicant will ensure that any information subsequently submitted to the Board in conjunction with this application or its
supporting documents meets the same standard as set forth above.
The licensee / applicant understands that this application will be classified as a public record and will be available for inspection by the
public, except with regard to the release of information classified as confidential pursuant to NRS 624.110.
The licensee / applicant understands that the Nevada State Contractors Board has the authority to conduct appropriate background
investigations for the purpose of verifying all statements and facts represented in this application and supporting documentation.
Signature Requirements: A principal of the applying company must sign this application.
By: _________________________________ Title: _________________
(Signature)
_________________________________ Date: _________________
(Print Name)
Nevada State Contractors
Board
Application for Conversion of Entity
(Revised 2/2020)
Page 6 of 9
NEVADA STATE CONTRACTORS BOARD APPLICANT BACKGROUND DISCLOSURE
STATEMENT AND AUTH
ORIZATION FOR RELEASE OF INFORMATION
A separate form MUST be completed by EACH Person including the Qualified Individual
BUSINESS NAME: ______________________________________________________
NRS 624.263 and NRS 624.265 authorizes the Nevada State Contractors Board (NSCB) to conduct background
investigations, obtain credit reports, and to request fingerprints for submission to the Nevada Highway Patrol (NHP) and the
FBI for a determination of identity, fugitive status or prior criminal history.
FINGERPRINT AND CRIMINAL BACKGROUND CHECKS
The Board will conduct a background check using information from the Federal Bureau of Investigations (FBI) and the Nevada Criminal History
Repository. These records are likely to include all instances of criminal activity, including those matters that may have been sealed, expunged, had the
charges reduced or dismissed. If a criminal history is found, an investigation will be conducted and you will be requested to provide supporting
documentation.
No
1. Have you ever been convicted of, or pled guilty or no contest to any crime, or, are any criminal charges pending against you?
Yes
Applications are not automatically denied because of information obtained through the background disclosure and criminal history verification. When
reviewing prior criminal convictions, the NSCB considers such additional factors as the seriousness of the crime, the time that has passed since the
conviction and any evidence of rehabilitation the applicant submits. It is your responsibility to provide any supporting documentation requested by the
Board related to any past convictions or pending criminal charges.
FINANCIAL DISCLOSURES
o You MUST disclose any unpaid or unresolved liens, lawsuits, judgments and claims, including tax claims.
o You are advised to obtain a copy of your credit report, Experian recommended, which will provide you with any unpaid, unresolved liens or
claims, all lawsuits, and all judgments. Pay particular attention to any tax claims or liens that have been made or filed against you.
o If you have entered into any repayment or credit consolidation agreements,
attach copies of those agreements to your
application, otherwise, we will assume you have not made arrangements to repay the debt.
2. Within the last 3 years, have you filed or been adjudicated Bankrupt under your individual name, a corporate name or any other business entity
name?
No Yes – Attach a complete copy of the proceedings, including a schedule of creditors listed in the bankruptcy petition. If the
bankruptcy has not been discharged, include your plan of reorganization and proof of compliance.
No
No
No
3. Do you anticipate filing bankruptcy within the next 6 months?
Yes
4. Hav
e you, or any business entities of which you were a member, partner, officer, director, or associate received any notice of liens, suits, judgments,
or
claims (including tax claims) which remain unresolved or unsatisfied – OR – Are there now any unpaid past due bills for materials,
services
r
endered,
o
r l
abor?
Yes
–
Attach a
detailed explanation.
5. Have you,
or
any
bus
iness
ent
ities
of
w
hich you were a
member,
partner,
of
ficer,
di
rector,
associate,
or
qualified employee
had
a
contractor’s license
denied,
suspended,
revoked, or otherwise disciplined BY NEVADA OR ANY OTHER STATE? Are there any disciplinary proceedings currently
pending against you, or any license on which you have appeared IN NEVADA OR ANY OTHER STATE?
Yes – Attach a detailed explanation including the name of the state in which the license was held, license number, and business name.
6. Do you have a proprietary interest (i.e., ownership, stock, shares) in this applicant? (This question does not pertain to sole proprietors).
No Yes – Percentage Owned: ________%
FIRST NAME MIDDLE NAME LAST NAME
SUFFIX DATE OF BIRTH
CITY & STATE OF BIRTH
SOCIAL SECURITY NUMBER
OTHER NAME USED
SEX
RACE
HEIGHT
WEIGHT
HAIR COLOR
EYE COLOR
RESIDENCE ADDRESS (AND MAILING ADDRESS IF DIFFERENT) CITY STATE ZIP
EMAIL ADDRESS
9
-
-
For Board Staff Only
Live Scan Prints
Hard Copy Prints
INDIVIDUAL TAX ID #
OR
A COPY OF THE FOLLOWING MUST BE PROVIDED WITH THIS FORM:
-
-
A valid Driver's License or Government Issued Photo I.D.
Nevada State Contractors Board
Application for Conversion of Entity
Revised 2/2020
P
age 7 of 9
In order to comply with the requirements of Nevada’s Department of Public Safety, fingerprint cards and LiveScan fingerprints cannot be
accepted until after
you submit your application and completed Fingerprint Background Waiver form(s) to the Board.
Once these forms has been submitted to the Nevada State Contractors Board you may proceed with obtaining the required fingerprints.
In consideration f
or processing my application for a Nevada State Contractor’s License, I, the undersigned whose name and personal
information voluntarily appear above, do hereby and irrevocably agree to the following:
1. I hereby authorize the NE
VADA STATE CONTRACTORS BOARD (hereinafter “BOARD”) to submit a set of my fingerprints to the
Nevada Department of Public Safety, Records Bureau for the purpose of accessing and reviewing Nevada and National criminal history
records that may pertain to me. In giving this authorization, I expressly understand that the information may include information pertaining to
notations of arrest, detainments, indictments, information or other charges for which the final court disposition is pending or is unknown to
the above referenced agencies. For records containing final court disposition information, I understand that the release may include
information pertaining to dismissals, acquittals, convictions, sentences, correctional supervision information and information concerning the
status of my parole or probation when applicable. Further, I understand that the information may include similar information obtained from
other local, state and federal criminal justice agencies and may include information pertaining to convicted person data, outstanding arrest
warrants, missing persons and current and/or prior gaming and non-gaming sheriff’s work cards that were issued to me.
2. I understand that I m
ay review and challenge the accuracy of any and all criminal history records which are returned to the BOARD.
3. I hereby release from
liability and promise to hold harmless under any and all causes of legal action, the State of Nevada, the Nevada State
Contractors Board, its officer(s), agent(s) and/or employee(s) who conducted my criminal history records search and provided information to
the BOARD for any statement(s), omission(s), or infringement(s) upon my current legal rights. I further release and promise to hold
harmless and covenant not to sue any persons, firms, institutions or agencies providing such information to the State of Nevada and the
BOARD on the basis of their disclosures. I have signed this release voluntarily and of my own free will.
4. In giving the above auth
orization, I understand that all information provided to the BOARD may be reviewed by the BOARD or any other
employee within the BOARD’S organization deemed necessary to make an informed decision. This information is confidential, as relating to
a third party beyond that of the BOARD and of the criminal justice agencies in the performance of their official duties, and may not be
further disseminated.
A reproduction of this authorization for release of information by photocopy, facsimile or similar process, shall for all purposes be as
valid as the original.
PURSUANT TO NRS 199.120, 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.
Signature: ____________________________________________ Date: _______________________
Nevada State Contractors Board
Application for Conversion of Entity
Revised 2/2020
P
age 8 of 9
FINGERPRINT BACKGROUND WAIVER
As an applicant who is the subject of a Federal Bureau of Investigation (FBI) fingerprint-based criminal history record check for a noncriminal justice purpose
you have certain rights which are discussed below.
1. You must be notified by the Nevada State Contractors Board that your fingerprints will be used to check the criminal history records of the FBI
and the State of Nevada.
2. If you have a crim
inal history record, the officials making a determination of your suitability for the job, license or other benefit for which you are
applying must provide you the opportunity to complete or challenge the accuracy of the information in the record. You may review and challenge the
accuracy of any and all criminal history records which are returned to the submitting agency. The proper forms and procedures will be furnished to
you by the Nevada Department of Public Safety, Records Bureau upon request. If you decide to challenge the accuracy or completeness of you FBI
criminal history record, Title 28 of the Code of Federal Regulations Section 16.34 provides for the proper procedure to do so:
16.34 - Procedure to obtain change, correction or updating of identification records.
If, after reviewing his/her identification record, the subject thereof believes that it is incorrect or incomplete in any respect and wishes
changes, corrections or updating of the alleged deficiency, he/she should make application directly to the agency which contributed the
questioned information. The subject of a record may also direct his/her challenge as to the accuracy or completeness of any entry on his/her
record to the FBI, Criminal Justice Information Services (CJIS) Division ATTN: SCU, Mod. D-2, 1000 Custer Hollow Road, Clarksburg, WV
26306. The FBI will then forward the challenge to the agency which submitted the data requesting that agency to verify or correct the
challenged entry. Upon the receipt of an official communication directly from the agency which contributed the original information, the FBI
CJIS Division will make any changes necessary in accordance with the information supplied by that agency.
3. Based on 28 CFR § 50.12 (b), officials making such determinations should not deny the license or employment based on information in the record
until the applicant has been afforded a reasonable time to correct or complete the record or has declined to do so.
4. You have the r
ight to expect that officials receiving the results of the fingerprint-based criminal history record check will use it only for authorized
purposes and will not retain or disseminate it in violation of federal or state statute, regulation or executive order, or rule, procedure or standard
established by the National Crime Prevention and Privacy Compact Council.
5. I hereby authorize (enter name of requesting agency Nevada State Contractors Board, to submit a set of my fingerprints to the Nevada
Department Public Safety, Records Bureau for the purpose of accessing and reviewing State of Nevada and FBI criminal history records that may
pertain to me.
In giving thi
s authorization, I expressly understand that the records may include information pertaining to notations of arrest, detainments, indictments,
information or other charges for which the final court disposition is pending or is unknown to the above referenced agency. For records containing
final court disposition information, I understand that the release may include information pertaining to dismissals, acquittals, convictions, sentences,
correctional supervision information and information concerning the status of my parole or probation when applicable.
6. I hereby release
from liability and promise to hold harmless under any and all causes of legal action, the State of Nevada, its officer(s), agent(s)
and/or employee(s) who conducted my criminal history records search and provided information to the submitting agency for any statement(s),
omission(s), or infringement(s) upon my current legal rights. I further release and promise to hold harmless and covenant not to sue any persons,
firms, institutions or agencies providing such information to the State of Nevada on the basis of their disclosures. I have signed this release
voluntarily and of my own free will.
A reproducti
on of this authorization for release of information by photocopy, facsimile or similar process, shall for all purposes be as valid as the original.
In consideration for processing my application I, the undersigned, whose name and signature voluntarily appears below; do hereby and irrevocably
agree to the above.
Applicant’s Name: _____________________________________________________________________________________________
(PLEASE PRINT LAST, FIRST, MIDDLE)
Address:_____________________________________________________________________________________________________
Applicant’s Signature: Date: ________________
Submitting Agency: NEVADA STATE CONTRACTORS BOARD .
Address: 5390 KIETZKE LANE, SUITE 102, RENO, NV 89511 / 2310 CORPORATE CIRCLE, SUITE 200, HENDERSON, NV 89074
Agency representative:____________________________________________________________________________________________
(PLEASE PRINT LAST, FIRST, MIDDLE
Agency representative’s Signature:________________________________________________________ Date: __________________
Nevada State Contractors Board Revised 02/2020
Application for Conversion of Entity
Page 9 of 9
NEVADA STATE CONTRACTORS BOARD
5390 KIETZKE LANE, SUITE 102, RENO, NEVADA, 89511 (775) 688-1141 FAX (775) 688-1271, INVESTIGATIONS (775) 688-1150
2310 CORPORATE CIRCLE, SUITE 200, HENDERSON, NEVADA 89074 (702) 4865-1100, INVESTIGATIONS (702) 486-1110
BANK VERIFICATION FORM
Name of Licensee/Applicant: _____________________________________________
Items 1 through 3 of the following report are to be completed by the applicant. Items 4 through 10 are to be completed by the
verifying bank. After completion by you and your bank, submit this form with your application.
3. Name and address of bank: ____________________________________________________
____________________________________________________
____________________________________________________
4. Signatures of account holder(s):
__________________________________ ______________________________________
Signature Print Name
__________________________________ _
______________________________________
Signature Print Name
5. Information to be verified:
Type of Account
Account Name
Account Number
TO VERIFYING BANK: Please furnish the information requested below.
4. Classification of Account: Individual Corporation Partnership
Limited Partnership Limited Liability Company
5. Deposit accounts of applicants:
*Account Name Type *Account Number *Current Balance
*Six (6) Month
Average
*Date Opened
*Required Information
6. Verification of Lines of Credit:
Line of Credit
Account #
Type of
Credit Line
Date
Opened
Approved
Amount
Current
Balance
Payments Required Secured by
$ Per
$ Per
7. Additional information that may be of assistance in determination of credit worthiness:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
8. Affix Bank Stamp or Business Card 9. Name and Title of Bank Representative
of Bank Representative here
__________________________
__________________________
10: Date: ________________________
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