OBL292 (10/2011)
Emission Station Only:
Has any principal of this business ever been convicted of felony Deceptive Trade Practices or felony Embezzlement?
Yes No If Yes, please provide the following information:
Full Name
Charge Date of Conviction
State County
If more space is needed, please use additional sheets.
Dealer Only:
Has any employee of this business ever been convicted or pleaded nolo contendere to a felony or gross misdemeanor or a
misdemeanor in violation of the provision of NRS 482 and NAC 482?
Yes No If Yes, please provide the following information:
Full Name
Charge Date of Conviction
State County
If more space is needed, please use additional sheets.
CERTIFICATE OF APPLICANT FOR PROGRAM LICENSING
Please initial next to each statement as acknowledgment that you have read and agree to all requirements of this program.
I agree to maintain a secure place of business with storage for secure supplies to restrict unauthorized
access.
I agree to comply with all requirements set forth in Nevada Revised Statutes and Nevada Administrative
Code pertaining to the program
.
VERIFICATION
I, (we), the undersigned hereby certify that under penalty of perjury, that I (we) am the applicant making the foregoing
application, and that the application has been read and the contents thereof and all statements contained herein are true,
correct and complete to the best of my knowledge and belief.
Signed Date
Subscribed and sworn before me this day of , 20
Notary Public or Authorized Nevada DMV Representative
State of Nevada County of
Application Accepted By:
Reviewed By: Approved: Yes No
Reason for Denial:
(Notary Seal)
