State of Nevada State Gaming Control Board / Nevada Gaming Commission Registration of Race Book and Sports Pool Employees NGC Regulation 22.035 requires any individual who fulfills the function of race book or sports pool manager, race book or sports pool supervisor, or who determines race book or sports pool betting odds, point spreads, or betting lines to register with the Board and provide the following information: This registration is for my employment with for the position of . I was placed in this position on . Mo./Day/Yr. 1. Personal Information Last Name First Name Middle Name Alias(es, Nicknames, Maiden Name, Other Name Changes, Legal or Otherwise) Date of Birth (Month/Day/Year) Place of Birth (City/County/State) Social Security Number Driver’s License Number and Issuing State Sex 2. Arrests and Detentions Have you ever been arrested, detained, charged, convicted, pleaded guilty or nolo contendere, indicted, or summoned to answer for any criminal offense, either felony or misdemeanor, or violation for any reason whatsoever, including any record expunged or sealed by a court Yes No order, regardless of the disposition of the event? (Except minor traffic citations.) If yes, give details in space provided below. List all cases without exception and furnish details on separate page, if necessary. Date of Arrest Charge Location – City and State Disposition Arresting Agency 3. Litigation Have you as an individual ever been a party to a lawsuit as either a plaintiff or defendant or an arbitration as either a claimant or Yes No respondent? If yes, give details below. List all cases without exception, including bankruptcies. Plaintiff/Defendant or Claimant/Respondent Date Filed Court and Case Number City/County/State Disposition/Date 4. Residences Please list all residences you have had for the last 5 years. Attach a separate sheet if necessary Month and Year (From – To) Street and Number City State/County/Zip Code - Page 1 of 2 Form 22_Race Book/Sports Pool Employee Registration (Rev. 02/06) American LegalNet, Inc. www.USCourtForms.com 5. Employment Beginning with your current employment, please provide a complete list of your work history you have had for the last 10 years. Attach a separate sheet if necessary. Month and Year (From – To) Name/Mailing Address of Employer/Business Position Held Duties - STATE OF ss. COUNTY OF I do hereby certify that the statements contained herein are true and correct and contain a full and true account of the information requested. I consent to a full licensing investigation by the State Gaming Control Board (“Board”) and Nevada Gaming Commission (“NGC”), subject to the provisions of NGC Regulation 22.035(3). I further consent to provide any additional information as may be required by the Chairman of the Board. REGISTRANT Signature SUBSCRIBED AND SWORN TO BEFORE ME THIS DAY OF , Notary Public (SEAL/STAMP) Page 2 of 2 American LegalNet, Inc. www.USCourtForms.com