Nonrestricted Licensee Request For Administrative Approval To Charge A Fee For Admission

STATE OF NEVADA GAMING CONTROL BOARD NONRESTRICTED LICENSEE REQUEST FOR ADMINISTRATIVE APPROVAL TO CHARGE A FEE FOR ADMISSION TO AN AREA IN WHICH GAMING IS CONDUCTED (The term "area" means "any portion of an establishment where any gaming is conducted, to which a fee is charged for admission" as defined in NGC Regulation 5.210(1)(a)) Nonrestricted Licensee Information: Location Name: Street Address: City, State, Zip Code: The failure to: (i) answer any of the following questions, or (ii) include a clear and legible diagram that depicts the number of games, slot machines and other gaming devices to be exposed for play as well as their location within the area which is the subject of this request, may result in denial of the request. (If space available is insufficient to answer a question, please use a separate sheet of paper.) What is the size of the area? What amount of gaming occurs or will occur within the area? What types and quantity of gaming are offered or will be offered within the area? What types and quantity of gaming are offered or will be offered outside the area? What is the business purpose of the area? 1 of 3 Admission Fee Form (Rev. 05/06) American LegalNet, Inc. www.FormsWorkflow.com What other amenities are offered or will be offered within the area? What are the total costs and expenses which have been, or are projected to be, incurred to create the area? What will be the benefit to the State of Nevada in having gaming conducted within the area? What is the maximum amount of the fee that will be charged to enter or remain in the area and is the fee to be charged reasonable as compared to the prevailing practice within the industry? Should the area more appropriately be treated as a gaming salon? (Please explain) If applicable, have your minimum internal control standards or the minimum internal control procedures applicable to the area been updated and approved by the Board? If applicable, have all current surveillance requirements applicable to the area been approved by the Board? 2 of 3 Admission Fee Form (Rev. 05/06) American LegalNet, Inc. www.FormsWorkflow.com If this request for administrative approval is granted, you shall be responsible for complying with all other provisions of NRS 463.15995 and NGC Regulation 5.210, including, but not limited to: 1. Depositing with the Board and thereafter maintaining a revolving fund in an amount of $5,000 unless a lower amount is approved by the Chairman, which shall be used to pay the expenses of agents of the Board and Commission to enter the area; 2. Arranging for immediate access by agents of the Board and Commission to the area; 3. At all times that a fee is charged for admission to an area, providing for the public at least the same number of gaming devices and games in a different area for which no fee is charged for admission; 4. Not using a fee charged for admission to create a private gaming area that is not operated in association or conjunction with a non-gaming activity, attraction or facility; 5. Not restricting admission to the area on the grounds of race, color, religion, national origin, or disability of the patron; and 6. Not increasing the amount of the fee, nor changing the number or location of the games or devices within the the area, without the prior administrative approval of the Chairman. Requests to change the number or location of any games or devices shall be accompanied by a diagram depicting the new location, and number of games and devices to be exposed within the area. Please mail this form, together with the above-referenced diagram, to: State Gaming Control Board Tax and License Division P.O. Box 8004 Carson City, Nevada 89702-8004 I, (Name) (Title) , certify and declare under the penalties of perjury that I am the of the nonrestricted licensee above; that the information contained herein is true, correct and complete to the best of my knowledge, information and belief; and that this request for administrative approval is made with knowledge and consent of all other individuals licensed. Furthermore, I hereby agrees to indemnify, hold harmless and defend, not excluding the State's right to participate, the State of Nevada, the Nevada Gaming Commission, the State Gaming Control Board, the Nevada Attorney General, and each of their members, agents, and employees in their individual and representative capacities from any and all claims, suits, and actions, brought by anyone associated with this request, or by any third party, against the agencies or persons named in this paragraph, arising out of the submission, investigation and deliberation of this request, and against any and all liabilities, expenses, damages, charges and costs, including court costs and attorneys' fees, which may be sustained by the persons and agencies named in this paragraph as a result of said claims, suits and actions. Printed Name Signature Date Contact Person Telephone Number RETURN ORIGINAL AND MAKE DUPLICATE FOR YOUR RECORDS 3 of 3 Admission Fee Form (Rev. 05/06) American LegalNet, Inc. www.FormsWorkflow.com