NEVADA STATE GAMING CONTROL BOARD Technology Division User's Installation of Associated Equipment Approval Request Location: Location #: Address: City: State: Contact Name: Zip: Title: Address: City: State: Phone #: Zip: Fax #: Email: Type of Associated Equipment: GCB #: Type of Installation: Manufacturer: Name / Model: Version: Attached to this approval request are all applicable internal control system amendments and/or any requests for regulation waivers. Yes or No Any licensee wishing to install associated equipment must complete and submit this form at least TEN DAYS prior to the intended installation date to the following address, fax or email: NGCB - Technology Division User Installation AE Request 750 Pilot Road, Suite H Las Vegas, NV 8911 Fax: 702-486-2241 submitae@gcb.nv.gov The undersigned, in compliance with NGC Regulation 14, requests installation of the above associated equipment. Furthermore the undersigned hereby agrees 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, employees in their individual and representative capacities from any and all claims, suits, and actions, brought by anyone associated with this request, or by any third party, against the agencies or persons named in this paragraph, arising out of the submission, investigation and deliberation of this request, and against any and all liabilities, expenses, damages, charges and costs, including court costs and attorneys' fees, which may be sustained by the persons and agencies named in this paragraph as a result of said claims, suits and actions. Printed Name Title Signature of Company Official Last Updated November 29, 2007 Date Instructions can be found at www.gaming.nv.gov to complete form. Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com