STATE OF NEVADA GAMING CONTROL BOARD JIM GIBBONS Governor 1919 E. College Parkway, P.O. Box 8003, Carson City, Nevada 89702 555 E. Washington Ave., Suite 2600, Las Vegas, Nevada 89101 3650 South Pointe Cir., P.O. Box 31109, Laughlin, Nevada 89028 557 W. Silver St., Suite 207, Elko, Nevada 89801 6980 Sierra Center Parkway, Reno, Nevada 89502 750 Pilot Road, Suite H, Las Vegas, Nevada 89119 DENNIS K. NEILANDER, Chairman RANDALL E. SAYRE, Member MARK A. LIPPARELLI, Member REQUEST FOR NEW TABLE GAME REVIEW PERSONAL HISTORY RECORD Table Game Approval for Unlicensed Applicants General Instructions Type or print an answer to every question, if a question does not apply to you, so state with N/A. If space available is insufficient, use a separate sheet and precede each answer with the appropriate title. Do not misstate or omit any material fact(s) as each statement made herein is subject to verification. Applicants must initial each page, as provided in the form’s upper right hand corner. By placing initials on the page, the applicant is attesting to the accuracy and completeness of the information contained on that page. All applicants are advised that this Personal History Record is an official document. Misrepresentation or failure to reveal requested information may be deemed as sufficient cause for the applicant to be called forward for a finding of suitability by the Nevada Gaming Commission. A Personal History Record must be completed by each Executive, Officer / Director and/or Equity Holder of greater than 10% or Key Employee of the developing corporation, limited liability company, partnership, etc. Federal and State laws make it unlawful to discriminate on the basis of race, color, religion, sex, national origin, handicap or age. ♦ Name of Game: _____________________________________________________ ♦ Type of Business Entity: EIN: ___________ ♦ Business Name: EIN: ___________ ♦ Business Address: ♦ City: ENF-104 (02/09) State: Zip Code: American LegalNet, Inc. www.FormsWorkflow.com Initials__________ A. PERSONAL INFORMATION: Last Name First Middle Alias (e.g., nicknames, name changes, maiden name) Residence Apt. # City/Town State Zip Code Mailing Address Apt. # City/Town State Zip Code Business Address Suite # City/Town State Zip Code Telephone Numbers Residence: (______) ______-__________ Business: (______) ______-__________ Cellular: Occupation (______) ______-__________ E-Mail Address Fax: Date of Birth Sex B. (______) ______-__________ Place of Birth (City, County, State) Eye Color Hair Color Height Social Security Number Weight ARRESTS, DETENTIONS, LITIGATIONS, AND ARBITRATIONS: Have you ever been arrested, detained, charged, indicted, or summoned to answer for any criminal offense or violation for any reason whatsoever, regardless of the disposition of the event? (Except minor traffic citations) Yes No If you answered yes, please provide details in the space listed below. Please include all arrests, including those in which you were not convicted. Continue on a separate sheet of paper if necessary. Date of Arrest Charge Arresting Agency City & State Disposition & Date Has a criminal indictment, information, or complaint ever been returned against you, for which you were not arrested or in which you were named as an un-indicted co-party? Yes No If yes, please furnish details on a separate sheet of paper. Have you ever been questioned or deposed by a city, county, state, federal law enforcement agency or commission or committee? (Except the Nevada Gaming Control Board and Commission.) Yes No Page 2 of 7 American LegalNet, Inc. www.FormsWorkflow.com Initials__________ If yes, please furnish details on a separate sheet of paper. Have you ever been subpoenaed to appear or testify before a federal, state, or county grand jury on a civil or criminal matter? Or before a Board or Commission on an Yes No administrative issue? If yes, please furnish details on a separate sheet of paper. Have you ever had a civil or criminal record expunged or sealed by a court order? Yes No If yes, when?_________ City, County and State ____________________ Have you ever received a pardon or deferred prosecution for any criminal offense? Yes No If yes, when?_______ City, County and State ____________________ Have you, as an individual, member of a partnership, owner, director, or officer of a corporation, ever been a party to a lawsuit as either a plaintiff or defendant or arbitration as either a claimant or respondent? Yes No If yes, give details below. Plaintiff/Defendant or Claimant/Respondent Date Filed Court and Case Number City, County & State Disposition & Date Has any general partnership, business venture, sole proprietorship, or closely held corporation (while you were associated with it as an owner, officer, director, or partner) been a party to a lawsuit, arbitration, or bankruptcy? Yes No If yes, give details below and on a separate page if necessary. Name of Entity Type of Entity Approximate Date(s) of Lawsuit/Arbitration/Bankruptcy Page 3 of 7 American LegalNet, Inc. www.FormsWorkflow.com Initials__________ C. RESIDENCES: List your current and previous residence: Month/Year From - To D. Street address, City, State, Zip Code EMPLOYMENT: List your current employment: Month & Year (From – To) Name/Mailing Address of Employer/Business Name of Supervisor Title Description of Duties Reason for Leaving Gaming Related Position? Yes E. No OTHER: Have you ever held a privileged or professional license in any state, including but not limited to the following types of licenses: Liquor Accountant Doctor Race Horse/ Race Dog Owner Boxing Promoter Lawyer Jockey Trainer or Manager Real Estate Broker or Salesman Other State where, years licensed and the nature of any disciplinary actions taken against you: Have you ever held a financial interest in a gambling venture, including a race track, dog track, race horse or dog, lottery, casino, bookmaking operation, or pari-mutuel operation, Yes No OUTSIDE the state of Nevada? If yes, state when and where and give names and locations of businesses in which you are/were involved and the names and addresses of all partners: Page 4 of 7 American LegalNet, Inc. www.FormsWorkflow.com Initials__________ Have you ever appeared before a licensing agency or similar authority in or outside the state of Nevada, for any reason whatsoever? Yes No If yes, indicate details: Have you ever been refused a gaming license or related finding of suitability or been a participant in any group which has been denied a gaming license or related finding of Yes No suitability? If yes, state when, where and for what reason: Have you ever been granted a gaming license or been a participant in any group which has been issued a gaming license by the state of Nevada? Yes No If yes, state type of license, name of establishment, location and period held: Have you ever been found suitable by the state of Nevada pursuant to NRS 463.167 or been a participant in any group which has been found suitable pursuant to NRS 463.167 Yes No by the state of Nevada? If yes, state type of license, name of establishment, location and period held: Have you ever been employed by the gaming industry in the state of Nevada or any other Yes No jurisdiction? If yes, state location, name of establishment, position and dates of employment: Page 5 of 7 American LegalNet, Inc. www.FormsWorkflow.com Initials__________ Do you have any relatives associated with or employed in the gaming industry? Yes No If yes, indicate details: F. CHILD SUPPORT INFORMATION: Please mark the appropriate response: I am not subject to a court order for the support of a child. I am subject to a court order for the support of one or more children and am in compliance with a plan approved by the district attorney or other public agency enforcing the order for the payment of the amount owed pursuant to the order; or I am subject to a court order for the support of one or more children and am NOT in compliance with a plan approved by the district attorney or other public agency enforcing the order for the payment of the amount owed pursuant to the order. Page 6 of 7 American LegalNet, Inc. www.FormsWorkflow.com Initials__________ STATE OF ___________________ ss. COUNTY OF _________________ I, ____________________________, being duly sworn, depose and say that I have read the foregoing application and know the contents thereof; that the statements contained herein are true and correct and contain a full and true account of the information requested; that I executed this statement with the knowledge that misrepresentation or failure to reveal information requested may be deemed sufficient cause for denial of the proposed new game; that I am voluntarily submitting this application with full knowledge that Nevada Revised Statute 463.140(5) provides “any person making false oath in any matter before either the Board or Commission is guilty of perjury”; and, further, that I have familiarized myself with the contents of the Nevada Gaming Control Act, as amended, and the Regulations of the Nevada Gaming Commission as promulgated thereunder and agree to abide thereby. I hereby expressly waive, release, and forever discharge the State of Nevada, the licensing agency, and their agents from any and all manner of action and causes of action whatsoever, which I, my administrators, or executors can, shall, or may have against the State of Nevada, the licensing agency and their agents, as a result of my applying for the approval of a new gambling game in the state of Nevada. _____________________________________ (Signature of Applicant) SUBSCRIBED AND SWORN TO BEFORE ME THIS_______ DAY OF ________________, ________ __________________________________________ (Signature of Notary Public) CERTIFICATION OF FORM Nevada Gaming Regulation 10.010 requires that every attorney, certified public accountant, or other agent who prepares this document on behalf of the applicant be properly enrolled with the Commission. Regulation 10.110 requires any such representative to certify such document. If this document was prepared by such a representative, please have that person complete the following: I, __________________________________________, do hereby certify that I am enrolled to (Representative’s Name) practice before the Nevada Gaming Commission and am fully knowledgeable of my responsibilities under Regulation 10. I further certify that I have prepared this document on behalf of the applicant in conformity with the Nevada Gaming Control Act and the Regulations of the Nevada Gaming Commission. ___________________________________ (Signature of Attorney, C.P.A., or Agent) ___________________________________ (Business Address) ________________________________________________________ ___________________________________ (Area Code/ Telephone) Page 7 of 7 American LegalNet, Inc. www.FormsWorkflow.com