PRIVATE SALE OF GAMING DEVICE REGULATION 14.330 APPLICATION The following is submitted pursuant to Nevada State Gaming Control Board Regulation 14.330. The Board's Enforcement Division must receive this form at least FIVE working days prior to the scheduled date of the sale. Sales limited to a total of two gaming devices per person per calendar year. SELLER Name ___________________________________________ ______________________________________ (Area Code) Telephone Number Address _________________________________________________________________________________ Social Security Number/Date of Birth _________________________________________________________ Driver's License Number/State _______________________________________________________________ Date/Location Device(s) Acquired #1. ______________________________________________________ #2. ______________________________________________________ Reason for Sale ___________________________________________________________________________ Expected Date & Time of Sale _______________________________________________________________ PURCHASER Name ___________________________________________ ______________________________________ (Area Code) Telephone Number Address __________________________________________________________________________________ Social Security Number/Date of Birth __________________________________________________________ Driver's License Number/State ________________________________________________________________ DESTINATION Name ___________________________________________ ______________________________________ (Area Code) Telephone Number Address __________________________________________________________________________________ Social Security Number/Date of Birth __________________________________________________________ Driver's License Number/State ________________________________________________________________ MANUFACTURER YEAR DESCRIPTION SERIAL # MODEL # DENOM PRICE I, _____________________________________, declare under penalty of perjury that each device will be used only for lawful purposes. Signature of Purchaser ______________________________________ Date _____________________ American LegalNet, Inc. www.USCourtForms.com