MULTI JURISDICTIONAL PERSONAL HISTORY DISCLOSURE FORM American LegalNet, Inc. www.FormsWorkFlow.com Initials Gaming Agency Date Form 7 MJPHDNV (Rev. 04/13/) Formatting (03/18) Page 2 of 66 MJQ0101 MULTI JURISDICTIONAL CASINO/GAMING LICENSE PERSONAL HISTORY DISCLOSURE FORM This application is designed to allow applicants for casino/gaming qualification to complete one form that is acceptable to several jurisdictions. The questions contained in this form have been designed to satisfy the variety of filing and informational requirements of the different jurisdictions that have agreed to accept this form as an application for qualification. Each jurisdiction accepting this form may require unique information and documentation that is not requested in this standardized form. Prior to completing this form, you should contact the appropriate agency in the jurisdictions where you are seeking qualification, licensure or approval and obtain copies of any documentation or forms that are supplemental to this standardized form. In addition, copies of this multi jurisdictional form and all supplemental forms used by the jurisdictions accepting this form may be found on the Internet at www.iagr.org. APPLICATION INSTRUCTIONS PLEASE READ ALL INSTRUCTIONS CAREFULLY BEFORE COMPLETING THIS FORM. I. COMPLETING THIS FORM: a. You must make accurate statements and include all material facts. Any misrepresentation, or the failure to provide requested information, may result in the denial of your application. b. Read each question carefully prior to answering. Answer every question completely. Do not leave blank spaces. If a question does nto that question. If there is nothing to disclose in response to a particular question, indicate in the rejection of your application. c. All entries on this form, except initials and signatures, must be typed or printed in block lettering using dark ink. If your application is not legible, it will not be accepted. d. You must use blue ink to personally initial, date and identify the gaming agency to which your application is being submitted in the space provided on the bottom of each page of the form. e. If the space available is insufficient to respond to a question, you are to supply the required information on an attachment page and clearly identify which question you are answering. The blank page on page 65 may be used to provide this additional information. You must use blue ink to personally initial, date and identify the gaming agency to which your application is being submitted at the bottom of each of these attachment pages. f. If you make any modification to the pre-printed questions or information contained in this form, your application will be rejected. Once your application is accepted, it becomes the property of the gaming agency with which it has been filed and will not be returned. American LegalNet, Inc. www.FormsWorkFlow.com Initials Gaming Agency Date Form 7 MJPHDNV (Rev. 04/13/) Formatting (03/18) Page 3 of 66 MJQ0101 II. BE SURE TO: a. Attach a recent (within the past six months) color photograph of yourself in the space provided on page 5. b. Sign the Statement of Truth form on page 66 in the presence of a notary public, justice of the peace, commissioner for declarations or other person legally authorized to notarize your signature. c. Check to ensure that you have placed your initials, the date, and identified the gaming agency to which you are applying, on the bottom of each page of this form in the space provided and on any attachment pages. III. BEFORE YOU SUBMIT THIS FORM TO THE GAMING AGENCY TO WHICH YOU ARE APPLYING, BE SURE THAT: a. ions for the type of license, approval or qualification that you are seeking. b. You have included all required attachments listed in this form. c. The Statement of Truth form is notarized on the original application. d. Every question has been answered completely. e. You retain a completed copy of your application package for your own records. f. You have completed any ancillary forms for the individual jurisdictions. IV. TIPS FOR COMPLETING THIS FORM: a. Keep a blank copy of the form. When you need to update information, you can use the appropriate pages from the blank form to provide the information. b. Once all questions have been answered, make sufficient copies for all jurisdictions where you will file your application. Note that you should do this BEFORE the form is signed, dated and notarized. Since each jurisdiction must receive an application containing original signatures, it is advisable to make copies before signing the form. c. Keep an unsigned copy of your completed application. Should you need to file with another jurisdiction at some point in the future, you can then update the information rather than complete the form all over again. d. Be sure to use blue ink where you sign, initial, date and identify the gaming agency where you are filing your application. Using blue ink will make it clear to the jurisdiction where you are filing that your application is to be considered an original and not a photocopy. American LegalNet, Inc. www.FormsWorkFlow.com Initials Gaming Agency Date Form 7 MJPHDNV (Rev. 04/13/) Formatting (03/18) Page 4 of 66 MJQ0101 MULTI JURISDICTIONAL CASINO/GAMING LICENSE PERSONAL HISTORY DISCLOSURE FORM PLEASE PRINT OR TYPE THE ANSWERS TO THE FOLLOWING QUESTIONS IN THE SPACES PROVIDED PERSONAL DATA NAME: LAST (INCLUDE SR., JR., ETC., IF APPLICABLE) FIRST MIDDLE MAILING ADDRESS/POSTAL ADDRESS: NUMBER AND STREET APT #/FLAT # CITY/TOWN STATE/PROVINCE ZIP/POSTAL CODE HOME ADDRESS: (IF DIFFERENT THAN MAILING ADDRESS/POSTAL ADDRESS) NUMBER AND STREET APT #/FLAT # CITY/TOWN STATE/PROVINCE ZIP/POSTAL CODE PRESENT BUSINESS ADDRESS: NUMBER AND STREET APT #/FLAT # CITY/TOWN STATE/PROVINCE ZIP/POSTAL CODE HOME TELEPHONE NUMBER: CURRENT BUSINESS TELEPHONE NO. AT PLACE OF EMPLOYMENT: FAX NUMBER: (AREA CODE) (NUMBER) (AREA CODE) (NUMBER) (EXTENSION) (AREA CODE) (NUMBER) DATE OF BIRTH: (MO)(DAY)(YEAR) E-MAIL ADDRESS (REQUIRED): HAVE YOU BEEN KNOWN BY ANY OTHER NAME OR NAMES? YES NO IF YES, LIST THE ADDITIONAL NAMES BELOW AND SPECIFY DATES OF USE FOR EACH. (INCLUDE MAIDEN NAME, ALIASES, NICKNAMES, OTHER NAME CHANGES, LEGAL OR OTHERWISE.) SEX COLOR OF EYES COLOR OF HAIR HEIGHT FT IN/ CM WEIGHT LBS/ KG DO YOU HAVE ANY SCARS, TATOOS, OR OTHER DISTINGUISHING MARKS AND/OR CHARACTERISTICS? IF SO, PLEASE DESCRIBE. American LegalNet, Inc. www.FormsWorkFlow.com Initials Gaming Agency Date Form 7 MJPHDNV (Rev. 04/13/) Formatting (03/18) Page 5 of 66 MJQ0101 IMPORTANT FAILURE TO ANSWER ANY QUESTION ON THIS FORM COMPLETELY AND TRUTHFULLY WILL RESULT IN DENIAL OF YOUR APPLICATION. AFFIX A COLOR PHOTOGRAPH HERE THAT WAS TAKEN WITHIN THE PAST SIX MONTHS. PRINT YOUR NAME ON THE FRONT BOTTOM BORDER OF THE PHOTOGRAPH BEFORE ATTACHING IT. American LegalNet, Inc. www.FormsWorkFlow.com Initials Gaming Agency Date Form 7 MJPHDNV (Rev. 04/13/) Formatting (03/18) Page 6 of 66 MJQ0101 1. Of what country are you a citizen? A. Please indicate: 1. Date of birth: DAY MONTH YEAR 2. Place of birth: CITY/TOWN STATE/PROVINCE COUNTRY 3. Country of birth: 2. Have you ever been issued a passport? Yes No If yes, provide the following information about your passport(s): PASSPORT NUMBER COUNTRY OF ISSUE PLACE ISSUED DATE ISSUED EXPIRATION DATE American LegalNet, Inc. www.FormsWorkFlow.com Initials Gaming Agency Date Form 7 MJPHDNV (Rev. 04/13/) Formatting (03/18) Page 7 of 66 MJQ0101 RESIDENCE DATA 3. Beginning with your current residence(s) and working backward, provide the following information with respect to each place where you have lived (including residences while attending college or while in military service) during the past fifteen (15) years or since the age of 18, whichever is less. DATES ADDRESS (NO., STREET, APT#/FLAT#, CITY/TOWN, STATE/PROVINCE, COUNTRY & ZIP/POSTAL COD E) OWN OR RENT NAME, ADDRESS & TELEPHONE NO. OF LANDLORD OR MORTGAGE/BOND HOLDER, IF KNOWN FROM: (MO/YR) TO: (MO/YR) American LegalNet, Inc. www.FormsWorkFlow.com Initials Gaming Agency Date Form 7 MJPHDNV (Rev. 04/13/) Formatting (03/18) Page 8 of 66 MJQ0101 FAMILY/SOCIAL DATA 4. What is your current mari