GAMING CONTROL BOARD REGULATION 22.061 LISTED PATRON APPROVAL PERSONAL INFORMATION Patron Name Date of application Other names patron has used or been known by Date of Birth Social Security Number Home Address Place of Birth Mailing Address City Home Phone Driver License Number State Expiration Date Current Employment State Zip City Business Phone State Zip Previous Driver's Licenses From Other States Employment Verified by Casino Yes Initials No PATRON'S BOOK WAGERING ACTIVITY AND ALL WAGERING ACCOUNT NUMBERS Account # Activity (Date opened ­ Total handle during last 12 month period) WHY DO YOU DESIRE TO HAVE THIS PERSON APPROVED AS A LISTED PATRON? TO THE BEST OF YOUR KNOWLEDGE IS THIS PATRON INVOLVED IN ILLEGAL WAGERING ACTIVITY? YES___________NO _____________ CASINO REPRESENTATIVE'S SIGNATURE _________________________________________________________________ TITLE _______________________________________ DATE_____________ PHOTO ENF 4 (12-98) American LegalNet, Inc. www.USCourtForms.com