STATE GAMING CONTROL BOARD INDEPENDENT AGENTS REPORT OF ARRANGEMENTS (Regulation 25.020) Independent Agent Collection Representative Every licensee who enters into any arrangement with an Independent Agent as defined in Regulation 25 shall cause each to provide the following information: A. Name and Address (Independent Agent) B. Business Name (if applicable): Business Address: Business Type: Sole Proprietorship Partnership Limited Liability Company (LLC) Association Corporation Other Attach narrative explanation if necessary. If business, partnership, association, or LLC, give full name, address, and nature of interest of all members thereof. If a corporation, furnish the same information for all officers, directors, or persons who hold an ownership interest of five (5) percent or more. Name Address % of Interest 1. 2. 3. Each person listed above must submit a Personal History Record (Form 4R). C. Do you have secondary representatives of other employees working for you? Yes No If yes, attach a list of all employees including Social Security Number and date of birth. D. Will your spouse, any member of your family or spouse’s family, have any involvement in the operation of junket activities? Yes No If yes, attach a list of all individuals involved including their Social Security Number, date of birth, and a detailed description of their duties and relationship to Independent Agent (i.e. partner, associate). 1 of 2 JR-08_Reg 25 (Rev. 02/06) American LegalNet, Inc. www.USCourtForms.com E. Gaming licensee for whom customers will be arranged: Casino Name Address Attach a copy of any documents evidencing the terms of any arrangement with the licensee named above for organizing of customers or the collection of credit. If no arrangement has been reduced to writing, attach a detailed written description of arrangements or agreements. F. Will Independent Agent be required to guarantee any payment due a licensee from any customer? Yes No If yes, attach a completed Personal Financial Questionnaire. G. Will Independent Agent be collecting any credit for the licensee? Yes No List all persons who may be utilized for collection of any credit which the Independent Agent has agreed to collect for a licensee. 1. 2. 3. STATE OF ss. COUNTY OF I, , being duly sworn, depose and say that the above Applicant’s Name statement is executed with the knowledge that misrepresentation or failure to reveal information requested may be deemed sufficient cause to require a Nevada gaming licensee to terminate all relationships with the Independent Agent. Further, that he/she is voluntarily submitting this filing under oath with the full knowledge that the Gaming Control Act (NRS 463.140(5)) provides “any person making false oath in any matter before either the board or commission is guilty of perjury.” INDEPENDENT AGENT Signature SUBSCRIBED AND SWORN TO BEFORE ME THIS DAY OF , Notary Public 2 of 2 American LegalNet, Inc. www.USCourtForms.com