STATE OF NEVADA GAMING CONTROL BOARD OFFICIAL USE ONLY CASE # CASE TYPE VOLUNTARY STATEMENT NAME (LAST / FIRST / MIDDLE) RACE SEX HEIGHT WEIGHT CITY HAIR EYES DATE OCCURRED TIME OCCURRED ID # DATE OF BIRTH HOME # ( ) STATE SOCIAL SECURITY # RESIDENCE ADDRESS (NUMBER & STREET) ZIP CODE EMPLOYER ADDRESS CITY STATE ZIP CODE EMPLOYER OCCUPATION WORK # WORK SCHDL. DAYS OFF I DO HEREBY MAKE THE FOLLOWING VOLUNTARY STATEMENT ON ______________________________________AT _____ AM/PM MONTH DAY YEAR I HAVE REVIEWED THIS STATEMENT OF _____PAGE(S) AND BELIEVE IT TO BE TRUE AND ACCURATE TO THE BEST OF MY RECOLLECTION. WITNESS SIGNATURE DATE PAGE OF PAGES ENF-12 (REV. 01-07) THIS COMPLETED FORM IS THE PROPERTY OF THE STATE OF NEVADA GAMING CONTROL BOARD PURSUANT TO NRS 463.120, AND MAY NOT BE DISTRIBUTED WITHOUT THE PERMISSION OF THE NEVADA GAMING CONTROL BOARD, OR ITS AUTHORIZED AGENTS, OR BY ORDER OF A COURT OF COMPETENT JURISDICTION American LegalNet, Inc. www.FormsWorkflow.com