Application-Marine-Event_0003.pdf

STATE OF NEVADA – Department of Wildlife SLAP 22.62/.63 Rev. Sept. 2019 A.M. Page 1 of 3

APPLICATION

MARINE EVENT PERMIT

Fee: Marine Event - $50 (22.62) Marine Event Charitable Organization – No Charge (22.63)

• Please PRINT all information except for your signature. Incomplete or illegible applications will be returned.

• SLAP Entity ID (Special Permit and License ID) - New applicants SLAP ID will be assigned when the permit is issued.

• Federal Tax ID or SSN only required for new applicants.

INSTITUTION OR BUSINESS ENTITY INFORMATION- (Institution or business entity the permit is for.)

INSTITUTION OR BUSINESS ENTITY NAME: (If same as responsible party indicate SAME)

SLAP Entity ID

MAILING ADDRESS: FEDERAL TAX ID:

CITY:

STATE: ZIP: E-MAIL ADDRESS:

PHYSICAL ADDRESS:

STATE: ZIP: TELEPHONE:

RESPONSIBLE PARTY– Person responsible for permit

NAME [LAST] [FIRST] [MIDDLE]

SLAP Entity ID

MAILING ADDRESS:

SSN

STATE: ZIP: E-MAIL ADDRESS:

PHYSICAL ADDRESS:

STATE: ZIP: TELEPHONE:

HEIGHT:

WEIGHT: HAIR: EYES: GENDER:

DRIVER’S LICENSE NUMBER

STATE: DATE ISSUED:

1. Have you conducted any marine events prior to this application? □ Yes □ No If yes, please list them:

2. Have you ever been convicted of a boating safety violation, an alcohol/drug-related offence or any felony?

□ Yes □ No If yes, please list them:

3. Name of Organization:

4. Location of Event:

5. Exact Times: 6. Exact Dates:

STATE OF NEVADA – Department of Wildlife SLAP 22.62/.63 Rev. Sept. 2019 A.M. Page 2 of 3

7. Description:

As part of the description attach a diagram showing boundaries of the event, water courses, buoy placement, areas for participation, officials, and spectators.

8. Estimated number of vessels:

A. Participants:

Participant vessel types and classes:

B. Spectators:

C. Safety Patrol:

9. Estimated number of participants:

10. Estimated number of spectators:

11. Special Requirements: (i.e. restricted movement of vessels and spectators through specified areas:

12. Motorboat noise exemption is hereby requested:

□ to compete in an approved marine event as provided in NRS 488.305.

□ to conduct trial runs between the hours of 9 a.m. and 5 p.m. for a period not to exceed 48 hours immediately preceding the marine event.

□ to compete in official trials for speed records between the hours of 9 a.m. and 5 p.m. for the period not to exceed 48 hours immediately following the marine event.

13. Safety requirements (i.e. safety patrols, unusual hazards, radio coordination, launching/retrieving buoys, the number and kind of navigational aids, rescue, medicinal, picket boats):

14. Do you have liability insurance? □ Yes □ No Amount:

Insurer: Insured:

15. Are there any potential adverse environmental effects or pollution concerns that may require an environmental assessment? □ Yes □ No If yes, describe (include any abatement plans)

16. Public sanitation concerns will be addressed as follows:

17. Have you contacted other agencies that may require a permit? □ Yes □ No If yes, agency name:

STATE OF NEVADA – Department of Wildlife SLAP 22.62/.63 Rev. Sept. 2019 A.M. Page 3 of 3

I, the signator, in signing this application, hereby state that I am entitled to this permit under the laws of the State of Nevada and that no false information or false statement has been made by me to obtain this license.

Signature of Applicant Date

Submit your completed application and fee to the appropriate office below:

Western Region Southern Region Nevada Department of Wildlife Nevada Department of Wildlife Special Licenses and Permits 3373 Pepper Ln.; Las Vegas, NV 89120 1100 Valley Rd, Reno, NV 89512 Telephone: (702) 486-5127 Telephone: (775) 688-1500 Counties: Clark, Esmeralda, Lincoln, Nye Counties: Carson City, Churchill, Douglas, Humboldt, Lyon, Mineral, Pershing, Storey, Washoe

Eastern Region Nevada Department of Wildlife 60 Youth Center Road; Elko, NV 89801 Telephone: (775) 777-2300 Counties: Elko, Eureka, Lander, White Pine

FOR DEPARTMENT USE ONLY

Department Representative: Date Received: _______________

Date Approved: _______________ Date Returned for Additional Information: _______________

Date Disapproved: _______________ Letter Sent:

REASON FOR DISAPPROVAL: