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City Of Yerington Business License Application Packet 14 E Goldfield Avenue, Yerington NV 89447 Phone: [PHONE REDACTED] Website: www.yerington.net Fax: [PHONE REDACTED] ---PAGE BREAK--- ---PAGE BREAK--- ---PAGE BREAK--- ---PAGE BREAK--- ---PAGE BREAK--- ---PAGE BREAK--- ---PAGE BREAK--- ---PAGE BREAK--- ---PAGE BREAK--- STATE OF NEVADA, OF INDUSTRIAL RELATIONS OF COMPLIANCE WITH MANDATORY INDUSTRIAL INSURANCE REQUIREMENTS (hwn1r1io11s 1t'itlt Def/nirio11s are located on rewr,c side) Ilusiucss l\'ome (Include any name doing business os) Type of Du5iness Business Telephone Number Address City S!nte Zip Colle ldeniificntion No. Board License No. Name or Principal Oworr Print) l'rincip11I Owner's-Telephone No. Principnl Owner's Address City Slate Zip Code Identified as: (Complete one section only) ( ) That the above identified business has obtained industrial workers' compensation insurance as required by Chapter 616A to D, inclusive, of the Nevada Revised Statutes (NRS): Effective Date of Coverage Account Number ( ) That the above identified business is not subject to the provisions of Chapter 616A to D, inclusive, of the Nevada Revised Statutes, due to a statutory exemption or as a business which has no employees nor hires any independent contractor or subcontractor. ( ) That the above identified business has a valid certificate of self-insurance pursuant to Chapter 616A to D, inclusive, of Nevada Revised Statutes. Effective Dale Ccrtifkalc Number I declare that I have the authority to acl on behalf of the above described business, and am applying for a license to operate said business as a ( ) Individual ( ) Sole Proprietor ( ) Partnership ( ) Corporation Nnme of Applinnf (Please Prinl) Applicon1's Trlephonc Number Residence Address City Slate Zip Code J do hereby affirm that the above informnlion is true and correct. DATED this day of 20 . SignRIUTC of Applicant (To be signed in the oflhe business license office ,:mployeu) Applicant's Tille Wi1nrss Signature - (Business Licen$r Office Employer) l"lfamc of City or County JfunabJe to sign this document in the presence of a Business License Employee, the Applicant's signature must be notarized. SUBSCRIBED and SWORN to before me on this day of , 20 NOTARY PUBLIC 0-25 ( 1) {rov, 3/01) ---PAGE BREAK--- CHILD SUPPORT INFORMATION Please mark the appropriate response (failure to mark one of these will resu1t in denial of the application). 1. I am not subject to a court order for the support of a child. 2. I am subject to a court order for the support of one or more children and I am in compliance with a plan approved by the District Attorney or other public agency enforcing the order or the repayment of the amount owed pursuant to the order. 3. I am subject to a court order for the support of one or more children and lam not in compliance with the order or plan by the District Attorney or other public agency enforcing the order for the repayment of the amount owed pursuant to the order. Please note at the bottom of this form, if said business is a partnership or corporation. Thank you in advance for your cooperation in this matter My Business is a partnership or corporation. Applicant's Name (Printed): Signature of Applicant: _ Date: ---PAGE BREAK---