STATE OF NEVADA GAMING CONTROL BOARD COUNT PERSONNEL LIST 6.130.1(b) SUBMIT TO EMAIL: TLCompliance@gcb.nv.gov TAX AND LICENSE DIVISION PO BOX 8004 CARSON CITY, NV 89702-8004 Account No., Name, Address, Zip Code For Office Use Only Batch Number Entry Date Please correct if in error 1 quarter: Due April 10 nd th 2 quarter: Due July 10 st th ~This report is for the (Use X to indicate application) SOFT HARD ALLOWED COUNT COUNT IN ROOM NAME POSITION 3 quarter: Due October 10 th th 4 quarter: Due January 10 rd th Quarter of NGC Regulation 6.130.1(b) requires all nonrestricted licensees to report the persons authorized to participate in the count and those employees who are authorized to be in the count room during the count. RELATIONSHIP TO LICENSEE SOCIAL SECURITY NUMBER OR OTHER EMPLOYEES (If necessary, attach additional sheets) List submitted by: (Name) (Position/Title) T&L/6.130.1(b) (09-13-2011) SUBMIT ORIGINAL ­ RETAIN COPY (Signature) (Date) American LegalNet, Inc. www.FormsWorkFlow.com