NEVADA STATE GAMING CONTROL BOARD Technology Division Associated Equipment Approval Request Requested By: Licensee #: Applied Date: Reference #: Type of Approval Request: Type of Associated Equipment: Manufacturer: Emergency: Original GCB #: Prior GCB #: Name / Model Version Features Supported: Attach Description All submissions must include a description of the functionalities or modifications made to the previously approved software, which fully describes all modifications. Any developer of associated equipment, whether a gaming licensee, a licensed manufacturer/distributor of gaming devices, or a manufacturer/distributor of associated equipment, must complete and submit this form before the review will be considered. Forms and required documentation must be submitted to the following address, fax or email: NGCB - Technology Division AE Approval Request 750 Pilot Road, Suite H Las Vegas, NV 8911 Fax: 702-486-2241 submitae@gcb.nv.gov Hardware and Software for the same associated equipment requires separate forms - DO NOT include both hardware and software on each form. In addition, a Personal History Record and Request to Release Information Form must be completed and submitted with this form for first-time applicants. Updates to the Personal History Record may be required at later dates. The Gaming Control Board charges for associated equipment reviews pursuant to NRS 463.670(5). Out-of-town travel expenses (lodging, meals, transportation, etc.) will be charged. Last Updated November 29, 2007 Instructions can be found at www.gaming.nv.gov to complete form. Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com I certify that: (a) The above information completely describes this request. (b) This software/hardware use is intended for the Nevada Market. (c) This software/hardware is in compliance with applicable Nevada Revised Statutes, Nevada Gaming Commission and State Gaming Control Board Regulations, Technical Standards and Minimum Internal Control Standards. (d) Copyrights are held by: (e) This software/hardware was designed and developed by: (Submitting Manufacturer) hereby agree to indemnify, hold harmless and defend, not excluding the State’s right to participate, the State of Nevada, the Nevada Gaming Commission, the State Gaming Control Board, the Nevada Attorney General and each of their members, agents, and employees in their individual and representative capacities from any and all claims against the agencies or persons named in this paragraph, arising out of the submission, application, investigation and deliberation concerning this application, and against all liabilities, expenses, damages, charges and costs, including court costs and attorney’s fees, which may be sustained by the person or agencies named in this paragraph as a result of said claims, suits and actions. Signature of Company Official Date First time applicants: Contact Name: Title: Address: City: Phone #: State: Zip: Fax #: Email: Last Updated November 29, 2007 Instructions can be found at www.gaming.nv.gov to complete form. Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com