Application To Conduct Racing (By An Individual) {9}

APPLICATION TO CONDUCT RACING (By an Individual) (To be typewritten or printed legibly) A. NAME OF APPLICANT Federal Tax I.D. No. Name of Racing Establishment Physical Address of Racing Establishment Mailing Address B. Individual Applicants: (Include name, percentage of interest, and/or position.) Attach additional sheet if necessary C. PLEASE MARK APPROPRIATE NUMBER(S): 1. New Location (Proposed date of opening 2. Application for Interest in Existing License: Purchased From: 3. Officer Treasury Director Individual ) % / Number of shares/units Other (Please specify) Key Employee Title(s) Written Employment Agreement: Yes No (If yes, attach a copy of the agreement.) D. NOTE: If this application is for C2 or C3, signature of a present licensee is required: Signature Name (Print) Title E. FEE(S) TO ACCOMPANY THIS APPLICATION: STATE (To be paid to Nevada Gaming Control Board): Nonrestricted Application - $500 per applicant and/or entity COUNTY: CITY: NOTE: APPROPRIATE BACK-UP MATERIAL MUST ACCOMPANY THIS APPLICATION TO STATE, CITY, AND/OR COUNTY, WHERE APPLICABLE. 1 of 2 Form 9_Application to Conduct Racing_Individual (Rev. 1/11) American LegalNet, Inc. www.FormsWorkFlow.com STATE OF ss. COUNTY OF I, Applicant's Name , being duly sworn, depose and say that the above statements are true and correct to the best of my knowledge and belief and that this statement is executed with the knowledge that misrepresentation or failure to reveal information requested may be deemed sufficient cause for the refusal to issue a gaming license by a municipality, or by a county or by the State of Nevada. Further, that I am aware that later discovery of an omission or misrepresentation made in the above statements may be grounds for the revocation of a gaming license. Further, that I am voluntarily submitting this application under oath with full knowledge that the Gaming Control Act (NRS 463.140(5)) provides that "Any person making false oath in any matter before either the board or commission is guilty of perjury." I am voluntarily submitting this application under oath with full knowledge that I may be required to submit this application to appropriate municipal and county authorities charged by law with granting gaming licenses. APPLICANT Signature SUBSCRIBED AND SWORN TO BEFORE ME THIS DAY OF , Notary Public NOTICE THIS APPLICATION MAY NOT BE WITHDRAWN WITHOUT THE PERMISSION OF THE LICENSING AGENCY 2 of 2 Form 9_Application to Conduct Racing_Individual (Rev. 1/11) American LegalNet, Inc. www.FormsWorkFlow.com