FG-700 FOREIGN GAMING NOTIFICATION STATEMENT BEFORE THE NEVADA GAMING COMMISSION AND THE STATE GAMING CONTROL BOARD _________________________________ In the Matter of EXACT NAME OF NEVADA LICENSEE Foreign Gaming Notification Statement NAME OF FOREIGN GAMING OPERATION FOREIGN LOCATION ADDRESS (e.g., 1234 XYZ St., Tunica, Mississippi) TYPE OF GAMING (e.g., Casino, Riverboat) 1. The Nevada Licensee State the Nevada licensees name and address. 2. Affiliated Companies State the name(s) and address(s) of any affiliated company, holding company, intermediary company or publicly traded corporation related to the Nevada licensee. 3. Notification Statement (a) Summary of the Proposed Operation and Related Agreements. Provide a summary of the proposed operations. DO NOT ATTACH THE AGREEMENTS. (b) Regulatory agency under which the licensee will operate. Provide the name, address, telephone number and contact person for the gaming regulatory agency responsible for regulating the foreign gaming operation. (c) License/Approval Sought. State what license(s) and/or approval(s) are being sought in the jurisdiction. (d) Partners or other third parties involved in the foreign gaming operation. Provide the name of any partner(s) or involved parties. For individuals include their full name, date of birth, social security number, business and residence addresses and their relationship to the licensee. For a business entity, provide the full name of the entity, its date of organization and jurisdiction in which it is >>>> 2organized, the name of the individuals who comprise its governing body (i.e., Board of Directors), its officers and its owners. (e) Nevada Licensees Relationships, Dealings or Arrangements. Provide a complete description of the relationships, dealings or arrangements between the Nevada licensee, the applicant, any affiliates, any third parties, any unaffiliated parties or foreign government. DO NOT ATTACH ANY AGREEMENTS OR DOCUMENTS. (f) Financing. Describe the type, amount and source of financing for the proposed gaming operation. (g) Administration of the Application. State when approval by the gaming regulatory agency listed in (b) is expected. (h) Expected opening date. Provide the expected date of commencement of gaming operations. The Nevada licensee shall keep the Boards Corporate Securities Division promptly informed of all actions taken by the foreign jurisdiction on the application(s) and the foreign gaming operation and all matters directly or indirectly related thereto. The Nevada licensee shall promptly, and in advance, inform the Corporate Securities Division when the applications will be publicly heard and/or acted upon by the foreign jurisdiction. Nevada Licensee By: Manual Signature___ Typed Signature Title