APPLICATION TO CONDUCT PARI-MUTUEL WAGERING (This application is filed pursuant to NRS 463 and 464) (To be typewritten or printed legibly) Federal Tax I.D. No. A. Name and Address of Applicant Mailing Address B. Individual Applicants (Include percentage of interest and/or position): (Attach additional sheet if necessary) C. Location(s) of events on which wagering will be conducted: D. This application is for pari-mutuel wagering for: E. Please enclose $500 application fee. NOTE: Sporting Events Racing Events Appropriate documents must accompany this application. (See Instruction Sheet) 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 charged 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By Signature Title SUBSCRIBED AND SWORN TO BEFORE ME THIS DAY OF , Notary Public NOTICE THIS APPLICATION MAY NOT BE WITHDRAWN WITHOUT THE PERMISSION OF THE LICENSING AGENCY Form 13_Application to Conduct Pari-Mutuel Wagering (Rev. 1/11) American LegalNet, Inc. www.FormsWorkFlow.com