REQUEST TO RELEASE INFORMATION (INDEPENDENT AGENTS) TO (Do Not Write Above This Line ­ For Gaming Control Board Use Only) FROM Independent Agent's Name (Please Print) NOTE: IF INDEPENDENT AGENT IS MARRIED, THE SPOUSE'S SIGNATURE IS REQUIRED BELOW. 1. I/We hereby authorize and request all persons to whom this request is presented having information relating to or concerning me/us to furnish such information to a duly appointed agent of the State Gaming Control Board of the State of Nevada, whether or not such information would otherwise be protected from disclosure by any constitutional, statutory, or common law privilege. I/We hereby authorize and request all persons to whom this request is presented having documents relating to or concerning me/us to permit a duly appointed agent of the State Gaming Control Board of the State of Nevada to review and copy any such documents, whether or not such documents would otherwise be protected from disclosure by any constitutional, statutory, or common law privilege. If the person to whom this request is presented is a brokerage firm, bank, savings and loan, or other financial institution or an officer of same, I/we hereby authorize and request that a duly appointed agent of the State Gaming Control Board of the State of Nevada be permitted to review and obtain copies of any and all documents, records, or correspondence pertaining to me/us, including but not limited to past loan information, notes co-signed by me/us, checking account records, savings deposit records, safe deposit box records, passbook records, and general ledger folio sheets. I/We do hereby make, constitute, and appoint any duly appointed agent of the State Gaming Control Board my/our true and lawful attorney in fact for me/us in my/our name, place, stead, and on my/our behalf and for my/our use and benefit: (a) To request, review, copy, sign for, or otherwise act for investigative purposes with respect to documents and information in the possession of the person to whom this request is presented as I/we might; (b) To name the person or entity to whom this request is presented and insert that person's name in the appropriate location on this request; (c) To place the name of the Gaming Control Board agent presenting this request in the appropriate location on this request. I/We grant to said attorney in fact full power and authority to do, take, and perform all and every act and thing whatsoever requisite, proper, or necessary to be done, in the exercise of any of the rights and powers herein granted, as fully to all intents and purposes as I/we might or could do if personally present, with full power of substitution or revocation, hereby ratifying and confirming all that said attorney in fact, or his substitute or substitutes, shall lawfully do or cause to be done by virtue of this power of attorney and the rights and powers herein granted. This power of attorney ends five (5) years from the date of execution. I the undersigned Independent Agent have filed with the State Gaming Control Board an "application" as that term is defined in NRS 463.0135 of the Nevada Gaming Commission and State Gaming Control Board. I understand that I am seeking the granting of a privilege and acknowledge that the burden of proving my qualifications for a favorable determination is at all times on me. I accept any risk of adverse public notice, embarrassment, criticism, or other action or financial loss which may result from action with respect to this application. I/We do, for myself/ourselves, my/our heirs, executors, administrators, successors and assigns, hereby release, remise, and forever discharge the person to whom this request is presented, and his agents and employees from all manner of actions, causes of action, suits, debts, judgments, executions, claims, and demands whatsoever, known or unknown, in law or equity, which I/we ever had, now have, may have, or claim to have against the person to whom this request is presented or his agents or employees arising out of or by reason of complying with this request. I/We agree to indemnify and hold harmless the person to whom this request is presented and his agents and employees from and against all claims, damages, losses, and expenses, including reasonable attorneys' fees arising out of or by reason of complying with this request. 2. 3. 4. 5. 6. 7. 8. 9. 10. A reproduction of this request by the Xerox or similar process shall be for all intents and purposes as valid as the original. 11. This authorization extends to the review and copy of any information protected from disclosure, privilege or obligation. IN WITNESS WHEREOF, I have executed this request at City , State on the day of _______________, Signature of Independent Agent SIGNED AND SWORN to before me this day of _______________, Notary Public IN WITNESS WHEREOF, I have executed this request at City , State on the day of _______________, Signature of Spouse SIGNED AND SWORN to before me this day of _______________, Signature of State Gaming Control Board agent presenting this request: Notary Public Date Form 18-IA Request to Release Information (Rev. 01/12) American LegalNet, Inc. www.FormsWorkFlow.com