Form 16 Due Diligence Form (Rev. 05/19) Page 1 of 2 NEVADA GAMING CONTROL BOARD DUE DILIGENCE FORM PURSUANT TO NGC REGULATION 5.011(5) Location Name: 5.011 Grounds for disciplinary action. The Board and the Commission deem any activity on the part of any licensee, his agents or employees, that is inimical to the public health, safety, morals, good order and general welfare of the people of the State of Nevada, or that would reflect or tend to reflect discredit upon the State of Nevada or the gaming industry, to be an unsuitable method of operation and shall be grounds for disciplinary action by the Board and the Commission in accordance with the Nevada Gaming Control Act and the regulations of the Board and the Commission. Without limiting the generality of the foregoing, the following acts or omissions may be determined to be unsuitable methods of operation: 5. Catering to, assisting, employing or associating with, either socially or in business affairs, persons of notorious or unsavory reputation or who have extensive police records, or persons who have defied congressional investigative committees, or other officially constituted bodies acting on behalf of the United States, or any state, or persons who are associated with or support subversive movements, or the employing either directly or through a contract, or any other means, of any firm or individual in any capacity where the repute of the State of Nevada or the gaming industry is liable to be damaged because of the unsuitability of the firm or individual or because of the unethical methods of operation of the firm or individual. Pursuant to the above-cited regulation, are there any events in the background of any of the owners, operators, or managers of the business operating entity, including sole proprietor, for this location, that could possibly be a factor in determining the suitability of the current application, pursuant to NGC Regulation 4.010? Yes No The following, examples, are events that should be disclosed, to include but are not limited to: General Suitability o Tax Liens (State and/or Federal) o Personal or Business Bankruptcy o Revocation or denial of a privileged or professional license o Litigation (Civil or Criminal) Character o Any arrest (including those that did not result in a conviction) o Convictions (Criminal record) (To include, but not limited to, failure to appear as a result of a traffic violation and DUI.) Integrity o Revocation or denial of a privileged or professional license o Associations o Immigration issues Any Other Factor By Virtue of the Nevada Gaming Control Act o Denied applicant or Revoked licensee o Gaming employee registration was previously objected to American LegalNet, Inc. www.FormsWorkFlow.com Form 16 Due Diligence Form (Rev. 05/19) Page 2 of 2 If yes, please provide details (for each owner principal): Due Diligence Form Pursuant to NGC Regulation 5.011(5) Location Name: Completed by: Printed Name/Title of Owner - Principal (Business Operator) Signature Date Printed Company Name (Business Operator) Reviewed by: Printe d Name/Title (Representative for Operator of Slot Machine Route) Signature Date American LegalNet, Inc. www.FormsWorkFlow.com