NEVADA STATE GAMING CONTROL BOARD Technology Division Gaming Device Hardware Modification Approval Request Manufacturer: Licensee #: Applied Date: Reference #: Original GCB #: Emergency: Prior GCB #: Name / Model Type of Hardware Features Supported by Hardware: Attach Description of Modification. All submissions must include a description of modifications made to the previously approved software which fully describes all modifications. I certify that: (a) The above information completely describes this request. (b) This hardware use is intended for the Nevada Market. (c) This 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 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 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