STATE OF N EVADA STATE GAMING CONTROL BOARD / N EVADA GAMING C OMMISSION REGISTRATION OF I NTERNATIONAL GAMING SALON EMPLOYEES NGC Regulation 5.200 requires any individual who fulfills the function of supervisor of an international gaming salon, or who is directly responsible for the operation of an international gaming salon, to register with the Board and provide the following information: This registration is for my employment at for the position of . I was placed in this position on Month/Day/Year 1. Personal Information Last Name First Name Middle Name Alias(es), Nicknames, Maiden Name, Other Name Changes, Legal or Otherwise Current Address Phone Number Emergency Contact Name/Phone Number Date of Birth Place of Birth (City, County, State) Driver’s License Number and Issuing State Social Security Number Work Permit Number Sex Female Male Expiration Date 2. Arrests and Detentions Have you ever been arrested, detained, charged, convicted, pleaded guilty or nolo contendere, indicted, or summoned to answer for any criminal offense, either felony or misdemeanor, or violation for any reason whatsoever, including any record expunged or sealed by a court order, regardless of the disposition of the event? (except minor traffic citations.) Yes No If yes, give details in space provided below. List all cases without exception and furnish details on separate page if necessary. Date of Arrest Charge Location – City and State Disposition Arresting Agency 3. Litigation Have you as an individual ever been a party to a lawsuit as either a plaintiff or defendant or an arbitration as either a claimant or respondent? Yes No If yes, give details below. List all cases without exception, including bankruptcies. Plaintiff/Defendant or Claimant/Respondent Date Filed Court and Case Number Page 1 of 2 City, County, and State Disposition/Date American LegalNet, Inc. www.USCourtForms.com 4. Residences Please list all residences you have had for the last 5 years. Attach a separate sheet if necessary. Month and Year (From – To) Street and Number City State, County, Zip Code 5. Employment Beginning with your current employment, please provide a complete list of your work history you have had for the last 10 years. Attach a separate sheet if necessary. Month and Year (From – To) Name/Mailing Address of Employer/Business Position Held Duties I __________________________________ being duly sworn, depose and say that I have read the foregoing registration 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 disciplinary action to be taken against me personally; that I am voluntarily submitting this registration with full knowledge that Nevada Revised Statutes 463.140(5) provides “any person making a false oath in any matter before either the Board or Commission is guilty of perjury.”; and, further, that I have familiarized myself with the requirements and procedures of the Gaming Control Act and Regulations promulgated there under as they would apply to the operation of an International Gaming Salon with special emphasis on Regulations 5.200, 6, 6A, and the minimum internal control standards for ______________________________, and agree to abide thereby. I, through the voluntary filing of this registration consent to a full licensing investigation, at the sole discretion of the State Gaming Control Board and Nevada Gaming Commission, subject to the provisions of NGC Regulation 5.200. I further consent to provide any additional information as may be required by the Chairman of the Board. 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 registration as an International Gaming Salon Employee in the State of Nevada. State of Nevada County of ____________________________________ __________________________________________ Signature Signed and sworn before me on ______________________ (Date) by _____________________________________________ (Name of person making statement) (Notary stamp) _______________________________________________ (Signature of notarial officer) THIS REGISTRATION IS PROPERTY SPECIFIC AND NON-TRANSFERABLE. THE BOARD MUST RESPOND TO THIS REGISTRATION REQUEST WITHIN FIFTEEN (15) DAYS OR IT IS DEEMED APPROVED WITHOUT FURTHER NOTIFICATION. Page 2 of 2 American LegalNet, Inc. www.USCourtForms.com