PERSONAL HISTORY RECORD REGISTRATION FOR FILING OF INDEPENDENT AGENT Date GENERAL INSTRUCTIONS Handprint or type an answer to every question. If a question does not apply to you, so state with N/A. If space available is insufficient, continue on supplemental page or use a separate sheet and precede each answer with the appropriate title. Do not misstate or omit any material fact(s) as each statement made herein is subject to verification. Applicant must initial each page, as provided in lower right hand corner. By placing his/her initials on each page, the applicant is attesting to the accuracy and completeness of the information contained on that page. All applicants are advised that this Personal History Record is an official document and misrepresentation or failure to reveal information requested may be deemed to be sufficient cause for the refusal or call forward for finding of suitability regarding the applicant. All applicants are further advised that an application for filing as an independent agent, finding of suitability, or for other action may not be withdrawn without the permission of the licensing agency. 1. GENERAL INFORMATION For which casino will you be performing Independent Agent activity? From what geographic area will you draw your customer base? Name of Independent Agent’s business Address of Independent Agent’s business 2. PERSONAL INFORMATION Last Name (Include Sr., Jr., etc., if applicable) First Name Middle Name Alias(es, Nicknames, Maiden Name, Other Name Changes, Legal or Otherwise) (Date) Apt. # City/Town State Zip Code Mailing Address (If Different Than Home Address) Apt. # City/Town State Zip Code City/Town State Zip Code Home Address: Since Present Business Name/Address: Since (Date) Telephone Numbers: Residence: ( ) - Business: ( ) - Cellular: ( ) - Fax: ( ) Date of Birth (Month/Day/Year) Age Sex Color of Eyes Occupation Color of Hair E-Mail Address (Optional) Place of Birth (City/County/State) Complexion Height Social Security No./Foreign I.D. No. Weight Build Scars, Tattoos, or Distinguishing Marks and/or Characteristics Country of citizenship If a non-U.S. citizen, Registration No. Date If naturalized U.S. citizen, Certificate No. Place (If Naturalized, document must be verified.) Applicant’s Initial -1Form 4R_IA PHR (Rev. 08/05) American LegalNet, Inc. www.USCourtForms.com 3. MARITAL INFORMATION Single Married A. Separated Divorced Widowed Engaged Current Marriage: Place (City/County/State) Date of Marriage Spouse’s Full Name (Maiden) Social Security Number/Foreign I.D. No. Date of Birth Place of Birth Residence Address Apt. # City/Town State Zip Code State Zip Code Telephone Residence ( ) - Business ( Spouse’s Employer Address of Employer B. ) Occupation City Previous Marriages: Name of Spouse If ever legally separated, divorced, or annulled, indicate below: Date of Order or Decree Date and Place of Marriage Nature of Action City/County/State List the names and current address of previous spouses: Name Street City Address State Zip Telephone ( ) - ( ) - ( ) - 4. ARREST INFORMATION Arrests, Detentions and Litigations: (List all arrests regardless of disposition, expunged or sealed.) A. Have you ever been arrested, detained, charged, indicted, or summoned to answer for any criminal offense or violation for any reason whatsoever, regardless of the disposition of the event? (Except minor traffic citations.) Yes No Date of Arrest Age Charge Location – City and State Disposition and Date Arresting Agency Applicant’s Initial -2- American LegalNet, Inc. www.USCourtForms.com ARREST INFORMATION – Continued B. Has a criminal indictment, information, or complaint ever been returned against you, but for which you were not arrested or in No If yes, furnish details. which you were named as an unindicted co-party? Yes C. Have you ever been questioned or deposed by a city, state, federal, or law enforcement agency, commission or committee? No Yes D. Have you ever been subpoenaed to appear or testify before a federal grand jury, board or commission? E. Have you ever had a civil or criminal record expunged or sealed by a court order? If yes, when?: F. Have you ever received a pardon for any criminal offense? H. Yes No No city, county, and state Has any member of your family or of your spouse’s family ever been convicted of a felony? If yes, complete the following: Name No city, county, and state If yes, when?: G. Yes Yes Relationship Date Yes Charge No Location Have you, as an individual, member of a partnership, or owner, director, or officer of a corporation or LLC, ever been a party to No (Other than divorces.) a lawsuit or arbitration as either a plaintiff or defendant? Yes If yes, give details below. List all cases without exception, including bankruptcies. (If bankruptcy, please furnish copies listing creditors and amounts discharged.) Date Filed Description of Lawsuit Court and Case Number City, County, and State Disposition/Date If your answer to any of the above questions (A through H) is yes, furnish details. 5. MILITARY INFORMATION Have you ever served in any armed forces? Yes No Branch Date of entry – active service Date of separation Type of discharge Rating at separation Serial number While in the military service were you ever arrested for an offense which resulted in summary action, a trial, or special or general court No martial? Yes If yes, furnish details below. (List all incidents regardless of where they occurred – foreign or domestic.) Applicant’s Initial -3- American LegalNet, Inc. www.USCourtForms.com 6. EDUCATION Name of School Location Dates Attended Graduate Grammar School Junior High School High School Yes No College/ University Yes No Other Type of degree obtained, if any College or University where obtained 7. FAMILY INFORMATION A. Children and Dependents: List all children, including step-children and adopted children and give the following information: Name B. Birth Date Birth Place Residence Address Child Support Information: Please mark the appropriate response: I am not subject to a court order for the support of a child. I am subject to a court order for the support of one or more children and am in compliance with a plan approved by the district attorney or other public agency enforcing the order for the repayment of the amount owed pursuant to the order; or I am subject to a court order for the support of one or more children and am NOT in compliance with the order or a plan approved by the district attorney or other public agency enforcing the order for the repayment of the amount owed pursuant to the order. District attorney or public agency responsible for enforcing the child support order: Name Address Contact Person Applicant’s Initial -4- American LegalNet, Inc. www.USCourtForms.com FAMILY INFORMATION – Continued C. Parents: List names, residence address, dates of birth, and most recent occupations of parents, parents-in-law, or legal guardian. If retired or deceased, list last address and occupation. Name (Maiden) Birth Date Address Occupation Father Mother Father-in-Law Mother-in-Law D. Brothers and Sisters: List names, residence address, dates of birth, and most recent occupations of brothers and sisters and of their respective spouses. Name (Maiden) Birth Date Address Occupation Sibling Spouse Sibling Spouse Sibling Spouse Sibling Spouse 8. RESIDENCES Beginning with your current residence, list all residences you have had for the last 10 years: Month and Year (From – To) Street and Number City State or County - Applicant’s Initial -5- American LegalNet, Inc. www.USCourtForms.com 9. EMPLOYMENT A. Beginning with your current employment, list your work history, all businesses with which you have been involved, and/or all periods of unemployment since 18 years of age. Month and Year (From – To) Name/Mailing Address/Type of Business/Phone Number Yes Title Is Business Incorporated? Description of Duties Reason for Leaving No Name of Supervisor/Title Gaming Present: Yes Month and Year (From – To) Name/Mailing Address/Type of Business/Phone Number Yes Title Is Business Incorporated? Description of Duties No Name of Supervisor/Title Gaming Present: Yes Month and Year (From – To) Name/Mailing Address/Type of Business/Phone Number Is Business Incorporated? Yes Title Description of Duties No Name of Supervisor/Title Name/Mailing Address/Type of Business/Phone Number Gaming Present: Is Business Incorporated? Yes Title Description of Duties No Name of Supervisor/Title Name/Mailing Address/Type of Business/Phone Number Gaming Present: Is Business Incorporated? Yes Title Description of Duties No Name of Supervisor/Title Name/Mailing Address/Type of Business/Phone Number Gaming Present: Is Business Incorporated? Yes Title Description of Duties No Name of Supervisor/Title Name/Mailing Address/Type of Business/Phone Number Gaming Present: Is Business Incorporated? Yes Title Description of Duties No Name of Supervisor/Title Name/Mailing Address/Type of Business/Phone Number Gaming Present: Is Business Incorporated? Yes Title Description of Duties No Name of Supervisor/Title Name/Mailing Address/Type of Business/Phone Number Gaming Present: Is Business Incorporated? Yes Title Description of Duties No Name of Supervisor/Title Name/Mailing Address/Type of Business/Phone Number Gaming Present: Is Business Incorporated? Yes Title Description of Duties No Name of Supervisor/Title Name/Mailing Address/Type of Business/Phone Number Gaming Present: Is Business Incorporated? Yes Title Description of Duties Name of Supervisor/Title No Reason for Leaving Yes Month and Year (From – To) No Reason for Leaving Yes Month and Year (From – To) No Reason for Leaving Yes Month and Year (From – To) No Reason for Leaving Yes Month and Year (From – To) No Reason for Leaving Yes Month and Year (From – To) No Reason for Leaving Yes Month and Year (From – To) No Reason for Leaving Yes Month and Year (From – To) No Reason for Leaving Yes Month and Year (From – To) No Reason for Leaving No Reason for Leaving No Gaming Present: Yes No Applicant’s Initial -6- American LegalNet, Inc. www.USCourtForms.com EMPLOYMENT – Continued B. List all corporations, partnerships, limited liability companies, or any other business ventures with which you have been associated as an officer, director, stockholder, member, or related capacity, since 18 years of age. Note: List only those entities not previously disclosed in section 9A, above. Month and Year (From – To) Name and Address of Firm, Corporation, or Other Business Entity Reason for Leaving Title of Office or Position Held Month and Year (From – To) Description of Duties Name and Address of Firm, Corporation, or Other Business Entity Reason for Leaving Title of Office or Position Held Month and Year (From – To) Description of Duties Name and Address of Firm, Corporation, or Other Business Entity Reason for Leaving Title of Office or Position Held Description of Duties 10. CHARACTER REFERENCES List five character references who have known you five years or more. Do not include relatives, present employer, or employees. Name and Where Employed Name Home Street, City, State, Zip Code Employer Business Name Home Employer Business Name Home Employer Business Name Home Employer Business Name Home Employer Telephone Business ( ) - ( ) - ( ) - ( ) - ( ) - ( ) - ( ) - ( ) - ( ) - ( ) Years Known - Applicant’s Initial -7- American LegalNet, Inc. www.USCourtForms.com 11. Have you ever held a privileged or professional license in any state, including but not limited to the following: Liquor Lawyer Race horse/race dog owner Securities dealer Insurance Real estate broker or salesman Doctor Jockey Contractor Gaming Accountant Boxing promoter Trainer or manager Pilot Yes No If yes, state type, where, dates held, and the nature of any disciplinary actions taken against you: 12. Have you ever held a financial interest in a gambling venture, including a race track, dog track, race horse or dog, lottery, casino, bookmaking operation, or pari-mutuel operation, OUTSIDE the State of Nevada? Yes No A. If yes, state when and where and give names and locations of the businesses in which you were involved and the names and addresses of all partners. B. Have you ever appeared before any licensing agency or similar authority in or outside the State of Nevada, for any reason No whatsoever? Yes If yes, submit details. 13. Have you ever been refused a gaming or liquor license or related finding of suitability or been a participant in any group which has been denied a gaming or liquor license or related finding of suitability? Yes No If yes, state where, when, and for what reason. 14. Have you ever been granted a gaming license or been a participant in any group which has been issued a gaming license by the State of Nevada? Yes No If yes, state type of license, name of establishment, location, and period held. 15. Have you registered as an Independent Agent with the Nevada Gaming Control Board in the last ten (10) years? Yes No A. If you were previously registered, but are not currently registered, list all casino properties where you were registered. B. If you are renewing your current registration, list all casino properties where you are registered. Applicant’s Initial -8- American LegalNet, Inc. www.USCourtForms.com 16. List all jurisdictions OUTSIDE the State of Nevada where you have been registered or licensed as an Independent Agent in the last ten (10) years. 17. Do you have any relatives associated with or employed in the gaming or liquor industry? Yes No If yes, state name, relationship, and association or employment. 18. If currently or previously employed in Nevada gaming, give dates and places of issuance of work permits and gaming employee registrations. 19. Are you currently indebted to a gaming licensee? Yes No If yes, describe the nature of the debt and the amount. 20. Have you had any personal indebtedness to a gaming licensee written off in the past three (3) years? Yes No If yes, describe the nature of the write-off and the amount. 21. Have you had any cash transactions exceeding $10,000 in the past three (3) years? Yes No ATTACH PHOTOGRAPH If yes, describe the transaction. TAKEN WITHIN LAST 30 DAYS HERE Applicant’s Initial -9- American LegalNet, Inc. www.USCourtForms.com STATE OF ___________________________ ss. COUNTY OF _________________________ , being duly sworn, depose and say that I have read the foregoing I, (Registrant’s Name) application and know the contents thereof; that the statements contained herein are true and correct and contain a full and true account of the information requested; that I executed this statement with the knowledge that misrepresentation or failure to reveal information requested may be deemed sufficient cause for denial or revocation of a state gaming license; that I am voluntarily submitting this application with full knowledge that Nevada Revised Statutes 463.140(5) provides “any person making false oath in any matter before either the Board or Commission is guilty of perjury.”; and, further, that I have familiarized myself with the contents of the Nevada Gaming Control Act, as amended, and the Regulations of the Nevada Gaming Commission as promulgated thereunder and agree, if licensed, to abide thereby. I hereby expressly waive release, and forever discharge the State of Nevada, the licensing agency and their agents from any and all manner of action and causes of action whatsoever which I, my administrators or executors can, shall, or may have against the State of Nevada, the licensing agency and their agents, as a result of my applying for a gaming license in the State of Nevada. Signature of Registrant SUBSCRIBED AND SWORN TO BEFORE ME THIS ___________ DAY OF _________________, _______ ______________________________________________ Signature of Notary Public (SEAL/STAMP) CERTIFICATION OF FORM Nevada Gaming Regulation 10.010 requires that every attorney, certified public account, or other agent who prepares this document on behalf of the registrant be properly enrolled with the Commission. Regulation 10.110 requires any such representative to certify such document. If this document was prepared by such a representative, please have that person complete the following: , do hereby certify that I am enrolled to practice before the Nevada I, (Representative’s Name) Gaming Commission and am fully knowledgeable of my responsibilities under Regulation 10. I further certify that I have prepared this document on behalf of the registrant in conformity with the Nevada Gaming Control Act and the Regulations of the Nevada Gaming Commission. (Signature of Attorney, C.P.A. or Agent) (Business Address) (Telephone) Applicant’s Initial - 10 - American LegalNet, Inc. www.USCourtForms.com ADDITIONAL INFORMATION Applicant’s Initial - 11 - American LegalNet, Inc. www.USCourtForms.com