APPLICATION FOR APPROVAL FROM NEVADA GAMING AUTHORITIES (To be typewritten or printed legibly) NATURE OF APPROVAL(S) REQUESTED: Approval to Participate in Pari-Mutuel Commissions License to Act as a Pari-Mutuel Systems Operator Other (Please specify) 1. Name of Applicant entity Business address (Nevada) Other Trade name to be used 2. Indicate whether applicant is a: Corporation Federal I.D. No. 3. Complete the following (If the applicant is a partnership, limited liability company, or other form of business organization, furnish similar information as that requested below): (a) State of incorporation/organization Date of qualification to do business in the State of Nevada (b) A certified copy of the Articles of Incorporation, Articles of Organization, or a true copy of the Partnership Yes No Agreement is attached: If no, state reasons (c) A general description of the nature of the business. (Attach a separate sheet if necessary) Date Partnership Limited Liability Company Other (d) A complete list of all stockholders, partners, or members showing the number of shares/interest held of Yes No record by each is filed herewith: If no, state reasons (e) List below the following information with respect to all partners, members, directors, officers, shareholders, and key employees. Each of the persons named below may be required to complete and file a Personal History Record/Disclosure and other related application documents. FULL NAME NATURE OF INTEREST TITLE Form 14_Application for Approval from Nevada Gaming Authorities (Rev. 1/11) -1- American LegalNet, Inc. www.FormsWorkFlow.com (f) If applicable, the terms, position, rights, and privileges of the different classes of securities outstanding: SECURITY TERMS AND POSITION RIGHTS AND PRIVILEGES (g) Options existing or to be created in respect of their securities or other interest: NAME ADDRESS TITLE OPTIONS (Shares) OR OTHER INTERESTS STATE OF ss. COUNTY OF I, , being duly sworn, depose and say that the above statements are true and correct to the best of my knowledge and belief and that this statement is executed with the knowledge that misrepresentation or failure to reveal information requested may be deemed sufficient cause for the refusal to issue a gaming license by a municipality, or by a county or by the State of Nevada. Further, that I am aware that later discovery of an omission or misrepresentation made in the above statements may be grounds for the revocation of a gaming license. Further, that I am voluntarily submitting this application under oath with full knowledge that the Gaming Control Act (NRS 463.140(5)) provides that "Any person making false oath in any matter before either the board or commission is guilty of perjury." I am voluntarily submitting this application under oath with full knowledge that I may be required to submit this application to appropriate municipal and county authorities charges by law with granting gaming licenses. APPLICANT Entity By Signature Title SUBSCRIBED AND SWORN TO BEFORE ME THIS DAY OF , Notary Public NOTICE THIS APPLICATION MAY NOT BE WITHDRAWN WITHOUT THE PERMISSION OF THE LICENSING AGENCY -2American LegalNet, Inc. www.FormsWorkFlow.com