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MARYLAND LOTTERY

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					THIS FORM IS AN OFFICAL DOCUMENT OF THE
MARYLAND STATE LOTTERY COMMISSION. IT CAN
NOT BE ALTERED OR CHANGED IN ANY FASHION,
EXCEPT TO FILL-IN THE AREAS PROVIDED WITH THE
INFORMATION THAT IS REQUIRED. ANY
ALTERATION OR CHANGE TO THIS DOCUMENT,
WHICH IS NOT WITHIN THE EXCEPTION, MAY CAUSE
THIS APPLICATION OR YOUR LICENSE TO BE
DELAYED OR DENIED.
         MARYLAND LOTTERY
            COMMISSION




              Principal Entity Application

  You must make accurate statements and include all material facts. Any
misrepresentations, failure to provide any requested information, or failure to
meet any other requirement as set out in the law or regulations, may result in
                         the denial of the application.




                                       1
               INSTRUCTIONS FOR PRINCIPAL ENTITY APPLICATION FORM

INSTRUCTIONS

THESE INSTRUCTIONS ARE APPLICABLE TO ANY “APPLICANT” THAT IS A PRINCIPAL,
PERSON WITH CONTROLLING INTEREST, INSTITUTIONAL INVESTOR OR FINANCIAL
INVESTOR WHO IS AN ENTITY.

Applicants for a license are seeking a privilege. The burden of proving qualifications to receive such a
license is at all times on the applicant. The applicant must accept any risk of adverse public notice,
embarrassment, criticism, or other action, of financial loss, which may result from action with respect to
any application, and expressly waives any claim for damages as result thereof. Information not called
for in this form or in addition to that which is provided in response to this form may be requested. The
applicant shall provide all information, documents, materials and certifications at the applicant’s sole
expense and cost.

The total cost of the investigation conducted pursuant to this application shall be borne by the applicant.
In addition, the applicant is responsible for the payment of all application fees required under the law
and regulations and the posting of a bond that may be required by the Commission.

The applicant is under a continuing duty to immediately disclose any changes in the information
provided in the application and requested materials submitted to the Commission. The duty to make
such additional disclosures shall continue throughout any period of the license that is granted by the
Commission.

All entries on the form must be typed or printed in block lettering. Initials or signatures must be in
handwriting, unless otherwise stated by the Commission, by the person providing the information. If the
answers are not legible, the application may not be accepted.

The applicant, if it is an individual, must initial only those pages that are so marked. If the applicant is
not an individual, the person authorized to complete the form on behalf of the applicant must initial the
pages that are so marked. If additional pages are required in order to answer any question, additional
pages may be utilized and must be attached to the form. Be sure to indicate the number(s) of the
question(s) being answered and initial each additional page. Some schedules may require disclosure of
information for more than one individual or entity or type of information. If there are multiple
disclosures, make enough additional copies of the blank schedule and complete it for each individual or
entity.

All required documentation, such as business formation papers, tax returns and appendices, as well as
the application forms that comprise an application package for a license, as listed above, must be
submitted at the time of filing this form. Further, the applicant is under a continuing duty to promptly
notify the Commission if there is a change in the information provided to the Commission.


 All notices regarding your application will be sent to the address you provide on this form. You must
immediately notify the Commission if you change your address.



                                                      2
Failure to answer any question completely and truthfully may result in denial of your application and/or
revocation of your license, registration, certificate or permit and may subject you to civil and/or criminal
penalties.

Any applicant who applies for and obtains a license from the Commission may be required to submit to
warrantless searches as stated in the law or regulation.

An Applicant should give specific attention to the clear identification of those portions of its application
that it deems to be confidential, proprietary commercial information or trade secrets, and provide
justification of why such materials, upon request, should not be disclosed by the State pursuant to the
Access to Public Records Act (“PIA”), Title 10, Subtitle 6, State Government Article, Annotated Code of
Maryland. Confidential information supplied shall be revealed in the course of the necessary
administration of this application. A blanket statement by an Applicant that its entire application is
confidential, proprietary commercial information or a trade secret is unacceptable. Application shall be
open to public inspection only after award of a license has been made, to the extent permitted by the
PIA. Applicant is advised that, upon request for this information from a third party, the Commission will
make an independent determination whether the information may be disclosed. An applicant or license
waives any liability of the State of Maryland, The Commission, the Maryland State Lottery Agency, the
employees of the Lottery and its instrumentalities and agents for any damages resulting from any
disclosure or publication in any manner.,

Additional financial information may be requested as needed.

Additional costs and expenses may be incurred by the Commission in its processing and investigation of
the applicant. If such added costs and expenses are assessed by the Commission, the applicant must
reimburse the Commission for these additional costs and expenses.

Read each question carefully prior to answering. Answer every question completely. Do not leave blank
spaces. If a question does not apply to the applicant, write “does not apply” in response to that question.
If a exhibit or addendum does not apply to the applicant, write “does not apply” on the exhibit or
addendum.

Appendices are to be provided by the applicant. The required appendices are listed on the application
checklist. Exhibits and Appendices must be presented in a tabbed manner. Each tab must indicate the
exhibit and appendix number. Immediately following the tab, applicant must insert a page with the
Exhibit or Appendix number and all information applicable to the exhibit or appendix.

The original along with all the forms attached to the application shall be attached to the original proposal
that is submitted in response to the request for proposal. Also, send a copy of this application and all
forms on a CD in PDF format in response to the request for proposal.




                                                     3
DEFINITIONS

Affiliate, affiliate of or person affiliated with - means “a person that directly or indirectly, through
one or more intermediaries, controls, is controlled by or is under common control with a specified
person.”

Applicant – means a person who applies for any license required under this subtitle.

Commission – means the State Lottery Commission

Controlling Interest - means a Publicly Traded Domestic or Foreign Corporation, a controlling interest
is an interest in a legal entity, applicant or licensee if a person’s sole voting right under Federal or State
law or corporate article of incorporation or bylaws entitles the person to elect or appoint one or more of
the members of the Board of Directors or other governing board or the ownership or beneficial holding
of 2% or more of the securities of the publicly traded corporation, Partnership, Limited Liability
Company or other form of Publicly Traded legal entity, unless the presumption of control or ability to
elect is rebutted by clear and convincing evidence. For a privately held Domestic or Foreign
Corporation, Partnership, Limited Liability or other form of privately held entity, a controlling interest is
the holding of any security in the legal entity, unless this presumption of control is rebutted by clear and
convincing evidence.

Director – means director as a director of a corporation, member of an audit committee or any person
performing similar functions with respect to an entity, whether incorporated or unincorporated.

Entity – entity is a person, other than an individual.

Financial backer – means an “an investor, mortgagee, bondholder, noteholder or other source of equity
or capital provided to an applicant or licensed entity.”

Holding company – means “a person, other than an individual, who, directly or indirectly, owns, has
the power or right to control or to vote 10% or more of the outstanding voting securities of a corporation
or other form of business organization. A holding company indirectly has, holds or owns any such
power, right or security if it does so through an interest in a subsidiary or successive subsidiaries”.

Indirect ownership interest – is defined as “an ownership interest in an entity that has a direct


                                                         4
ownership interest in an applicant or licensee, or a direct ownership interest in an entity that has an
ownership interest in an applicant or licensee through one or more intervening entities.”


Individual – defined as “a natural person.”


Intermediary – is defined as “a person, other than an individual, which:

               (1) is a holding company with respect to a corporation or other form of business
               organization, which holds or applies for a license under this part; and

               (2) is a subsidiary with respect to any holding company.


Institutional investor – is defined as “a retirement fund administered by a public agency for the
exclusive benefit of federal, state or local public employees; investment company registered under the
investment company act of 1940 (15 U.S.C.A. §§ 80a-1 – 80a-64); collective investment trust organized
by banks under part nine of the rules of the comptroller of the currency; closed end investment trust;
chartered or licensed life insurance company or property and casualty insurance company; banking and
other chartered or licensed lending institution, investment advisor registered under the investment
advisors act of 1940 (15 U.S.C.A. §§ 80b-1 – 80b-210; and other persons registered in any foreign
jurisdiction and regulated pursuant to a statute of any foreign jurisdiction that the Commission
determines to be substantially similar to either or both of the aforementioned statutes.”

Key employee- defined as “an individual who is: (i) employed in a director or department head capacity
and who is empowered to make discretionary decisions that regulate slot machine operations in this
commonwealth, including the general manager and assistant manager of the licensed facility, director of
video lottery operations, director of cage operations, director of surveillance, director of marketing,
director of management information systems, director of security, director of human resources,
comptroller and any employee who supervises the operations of these departments or to whom these
department directors or department heads report; (ii) employed by a video lottery machine licensee,
manufacturer licensee or supplier licensee whose duties affect or require contact with video lottery
machines, video lottery monitoring systems, casino management systems, player tracking systems and
wide-area progressive systems for use or play in this state, whether or not the individual is assigned to
gaming operations in this state; (iii) a sales representative seeking to sell video lottery machines and
associated equipment for use in this state on behalf of a licensed manufacturer, manufacturer designee or
supplier and (iv) employed in other positions which the Commission will determine based on detailed
analyses of the employee’s duties or the job descriptions.”

Lending institution – defined as “a person who has been issued a license to lend money by a state or
federal agency or a person who satisfies the definition of “qualified institutional buyer” pursuant to 17
C.F.R. § 230.144a (relating to private resale of securities to institutions).”

Officer –defined as “a president, chief executive officer, chief operating officer, secretary, treasurer,
principal legal officer, principal compliance officer, principal financial officer, comptroller, principal



                                                    5
accounting officer, chief engineer or technical officer of a manufacturer, or principal video lottery
operations officer of a video lottery machine licensee and any person routinely performing
corresponding functions with respect to an entity whether incorporated or unincorporated.”

Person - includes any individual, association, corporation, club, trust, estate, society, company, joint
stock company, receiver, trustee, assignee, referee, or any other person acting in a fiduciary or
representative capacity, whether appointed by a court or otherwise, and any combination of individuals.
"Person" also means and includes all departments, commissions, agencies, and instrumentalities of the
State, including counties and municipalities and agencies and instrumentalities of them.

Principal - defined as “an officer; director; person who directly holds a beneficial interest in or
ownership of the securities of an applicant or licensee; person who has a controlling interest in an
applicant or licensee, or has the ability to elect a majority of the board of directors of a licensee or to
otherwise control a licensee; lender or other licensed financial institution of an applicant or licensee,
other than a bank or lending institution which makes a loan or holds a mortgage or other lien acquired in
the ordinary course of business; underwriter of an applicant or licensee; or other person or employee of
an applicant, video lottery machine licensee, manufacturer licensee or supplier licensee deemed to be a
principal by the Commission.”

Principal affiliate –defined as “an intermediary or holding company of an applicant or licensee.”

Principal entity –defined as “an entity that meets the definition of principal or is otherwise required to
be licensed as a principal and is not an intermediary or holding company of an applicant or licensee.”

Private investment fund – defined as “an entity that meets the definition of “investment company”
under section 3(a)(1) of the investment company act of 1940 (15 U.S.C. § 80a-3(a)(1)), but is otherwise
exempt from the definition of “investment company” under section 3(c)(7) of the investment company
act of 1940 (15 U.S.C. § 80a-3 (c)(7)).

Publicly traded corporation – defined as “a person, other than an individual, which:

               (1) has a class or series of securities registered under the securities exchange act of 1934
               (48 stat. 881, 15 U.S.C. § 78a et seq.);

               (2) is a registered management company under the investment company act of 1940 (54
               stat. 789, 15 U.S.C. § 80a-1 et seq.);

               (3) is subject to the reporting obligations imposed by section 15(d) of the securities
               exchange act of 1934 by reason of having filed a registration statement which has become
               effective under the securities act of 1933 (48 stat. 74, 15 U.S.C. § 77a et seq.);”or

               (4) company that files a registration statement with the Security and Exchange
               Commission


Registered investment advisor - define registered investment adviser as an investment adviser that has
registered with the sec under the investment advisers act of 1940.”


                                                    6
Registered Investment Company –defined as “an investment company that has registered with the sec
under the investment company act of 1940.”

Subsidiary –defined as “a person other than an individual. The term includes:

              (1) a corporation, any significant part of whose outstanding equity securities are owned,
              subject to a power or right of control, or held with power to vote, by a holding company
              or an intermediary company;

              (2) a significant interest in a person, other than an individual, which is owned, subject to
              a power or right of control, or held with power to vote, by a holding company or an
              intermediary company; or

              (3) a person deemed to be a subsidiary by the Commission.”


Video Lottery Operation License – defined as “a license issued to a person that allows players to
operate video lottery terminals”.

Voting security – defined as “a security or other interest which entitles the owner to vote for the
election of:

              (i) a director of a corporation.

              (ii) a person performing functions similar to a director with respect to an organization,
              whether incorporated or unincorporated.”




                        LEFT BLANK INTENTIONALLY




                                                   7
                                           APPLICANT INFORMATION

APPLICANT IS A PRINCIPAL ENTITY FOR THE FOLLOWING VIDEO LOTTERY OPERATION
LICENSE APPLICANT:
_________________________________________________________

NAME OF APPLICANT*

____________________________________________________________________________
* As it is written on the Articles of Incorporation, By-laws or other official documents filed with the State or Federal Government
____________________________________________________________________________
D/B/A or TRADE NAME(S)



CONTACT NAME FOR THIS APPLICATION

_____________________________________________________________________________
Name                                      Title

______________________________________(_____)_________________(____)___________
e-mail address                                     Telephone: (Area Code) Number                       Fax Number


APPLICANT’S PRINCIPLE ADDRESS
____________________________________________________________________________________________
Address Line 1 (Street Location)

____________________________________________________________________________________________
Address Line 2

____________________________________________________________________________________________
City                                State                                      Zip

____________________________________________________________________________________________
Address 3 (Mailing Address-If different from above)

___________________________________________________________________________________________
Address 4

____________________________________________________________________________________________
City                                State                                      Zip

____________________________________________ (_______)_____________________(_____)____________
Country                             Telephone: (Area Code) Number        Fax Number

_____________________________________________________________________________________________
Web Site Address
APPLICANT’S FORM OF ORGANIZATION
CHECK ONE
□ Sole Proprietorship       □ Partnership       □ Limited Partnership     □ C-Corporation
□ Limited Liability Company □ S-Corporation     □ Trust
□ Other (Describe) _____________________________________________________________
                                                                       8
1. INCORPORATION

     a) APPLICANT’S INCORPORATION DOCUMENTS

     Business name as it appears on formation documents:_________________________________________

     Place of Incorporation or other type of Formation_____________________________________________

     Date of Formation: __________________________________________________________________________

     List all States in which the Applicant is currently registered or authorized to do business:
     _____________________________________________________________________________________________

     Is the Applicant registered to do business in Maryland:   □ Yes      □ No
     If yes, please provide registration number: ___________________________________________________

     Complete Exhibit 1a providing Applicants Incorporators/Founders.


     b) OTHER NAMES AND ADDRESSES OF APPLICANT

     1.     Use Exhibit 1b to list all other names in which Applicant has done business and give the
            approximate time periods during which these names were being used.

     2.     Use Exhibit 1c to provide all the current address of Applicant and all current addresses
            from which the Applicant is doing business.

     3.     Use Exhibit 1d to provide all addresses, other then those listed in Exhibit 1c, which
            Applicant has used or from which it was conducting business during the last ten (10) year
            period, and list the approximate dates during which said addresses were held.

     C)     Use Exhibit 1e to describe the relationship between the Applicant for the Video Lottery
            Operation License and the Business Entity named above, include any terms and
            conditions that effect ownership or control.

2.   DIRECTORS, PARTNERS, OFFICERS AND TRUSTEES

     Use Exhibit 2 to provide information for each Director, Partner, Officer and Trustee of the
     applicant. Include any Grantors or Beneficiaries of a Trust that is required to be licensed as a
     principal as defined in this application. (IMPORTANT: It is a requirement, as part of this
     application, that each Director, Partner, Officer and Trustee complete a Multi-jurisdictional
     Personal History Disclosure Form and a Principal Employee Form – Maryland Supplement to
     the Multi-jurisdictional Personal History Disclosure Form.)


                                                  9
3.     OWNERS OF APPLICANT
       Use Exhibit 3 to provide each person who has a direct ownership interest in a Video Lottery
       Facility Operation Applicant and all individuals and Trust who have a 1% or greater indirect
       ownership interest in a Video Lottery Facility Operation Applicant.

4.      CRIMINAL HISTORY

       THIS SECTION ASKS ABOUT ANY OFFENSES OR CHARGES APPLICANT OR ANY OF
       ITS SUBSIDIARIES OR ANY OF ITS OFFICERS, DIRECTOR, TRUSTEES OR PARTNERS
       MAY HAVE COMMITTED OR HAD FILED AGAINST THEM. PRIOR TO ANSWERING
       THIS QUESTION, CAREFULLY REVIEW THE DEFINITIONS AND INSTRUCTIONS
       THAT FOLLOW.

Definitions:            For the purpose of this section only:

       A.       "ARREST" includes any time that you were stopped by a police officer or other law
                enforcement officer and advised that you were under arrest, detained, held for
                questioning, requested by a police officer or law enforcement officer to come to a police
                station and answer questions, taken into custody by any police officer or other law
                enforcement officer, fingerprinted, held in jail, or instructed to appear in court or
                subpoenaed to answer for conduct which is a crime as has been defined in paragraph “C.”

       B.       "CHARGE" includes any indictment, complaint, information, summons, citation or other
                notice of the alleged commission of any crime or offense as defined in paragraph “C.”

       C.       "CRIME    OR OFFENSE" includes all felonies and misdemeanors, as well as summary
                offenses that may have required you to appear before a law enforcement agency, state or
                federal grand jury, justice court, municipal court, city court, traffic court, military court or
                any other court except juvenile court. Include all DUI/DWI offenses.

Instructions:

       A.       ANSWER "YES" AND PROVIDE ALL INFORMATION TO THE BEST OF YOUR
                ABILITY EVEN IF:

                1.      You did not commit the offense charged;
                2.      The Arrest, charges or offense happened a long time ago;
                3.      You were not convicted;
                4.      The arrest or charges were dismissed;
                5.      The charges were downgraded to a lesser charge;
                6.      You pleaded nolo contendere to the charges;
                7.      You completed any type of rehabilitative or diversionary program;
                8.      You were not convicted or found guilty;


                                                      10
            9.      The conviction was expunged from your record;
            10.     No time was served in any type of correctional facility.

     B.     Answer “no” if:

            1.      You have never been charged or arrested with any crime or offense;
            2.      Your arrest happened when you were under eighteen (18) years of age and your
                    court appearance was in Juvenile court.


     Question 1: Has the Applicant or any of its subsidiaries, principals, directors, partners, trustees
     or officers ever been indicted, charged with or convicted of a criminal offense or been a party to
     or named as an unindited co-conspirator in any criminal proceeding in this state or any other
     jurisdiction? (Criminal Offenses shall, include but are not limited to any felony, misdemeanor or
     gambling offense)

                                                                    ________ YES ________ NO


     If yes, use Exhibit 4 to provide information concerning criminal history.

5.   INVESTIGATION, TESTIMONY OR POLYGRAPHS
     Has the Applicant, any of its subsidiaries, principals, directors, partners, trustees or officers ever
     been called to testify before, been the subject of an investigation conducted by, or requested to
     take a polygraph exam by any governmental agency, court, committee, grand jury or
     investigatory body (municipal, state, county, provincial, federal, national, etc.) other than in
     response to minor traffic related offenses?


                                                            ____________ Yes _____________ No

     If yes, use Exhibit 5 to provide the following information about any such testimony,
     investigation or polygraph exam.

6.   EXISTING AND PAST LITIGATION
     Use Exhibit 6 to describe all existing civil litigation or any settled or closed legal action over the
     past three (3) years to which the Applicant, its parent, affiliate, holding or any subsidiary is or
     was a party whether in this state or in another jurisdiction. This description must include the title
     and docket number of the litigation, the name and location of the court before which it is
     pending, the identity of all parties to the litigation, the general nature of all claims being made
     and the nature of any judgments. List most recent litigation first.




                                                   11
7.   ANTITRUST, TRADE REGULATION & SECURITIES JUDGMENT;
     STATUTORY AND REGULATORY VIOLATIONS
     A.     Has the corporation ever had a judgment, order, consent decree or consent order
            pertaining to a violation or alleged violation of the federal antitrust, trade regulation or
            securities laws, or similar laws of any state, province or country entered against it?

                                                           ____________ Yes _____________ No

     B.     In the past ten years, has the corporation had a judgment, order, consent decree or consent
            order pertaining to any state or federal statute, regulation or code that resulted in a fine or
            penalty of $50,000 or more entered against it?

                                                           ____________ Yes _____________ No

     If yes to either question, use Exhibit 7 to provide the following information for each judgment,
     order, consent decree or consent order.

8.   BANKRUPTCY OR INSOLVENCY PROCEEDINGS
     A.     Has the Applicant, or any Affiliate, Intermediary, Subsidiary or Holding company had
            any petition under any provision of the Federal Bankruptcy Code or under any state
            insolvency law filed by or against it in the last ten year period?

                                                           ____________ Yes _____________ No

     B.     Has the Applicant, or any Affiliate, Intermediary, Subsidiary or Holding company sought
            relief under any provision of the Federal Bankruptcy Code or under any state insolvency
            law in the last ten year period?

                                                           ____________ Yes _____________ No

     C.     Has any receiver, fiscal agent, trustee, reorganization trustee, or similar officer been
            appointed in the last ten year period by a court for the business or property of the
            Applicant, or any Affiliate, Intermediary, Subsidiary or Holding companies?

                                                           ____________ Yes _____________ No

            If yes to either question, use Exhibit 8 to provide the following information for each
            bankruptcy or insolvency proceeding.




                                                  12
9.   LICENSES (Gaming and Non-gaming)

     A.   Has the Applicant, or any Affiliate, Intermediary, Subsidiary or Holding company ever
          applied in any jurisdiction, including, but not limited to any Federal, State, Local or
          Native American Governments for a license, permit or other authorization to participate
          in lawful gambling operations (including slot machines, video lottery terminals, table
          gaming, horse racing, dog racing, pari-mutuel operation etc.)?

                                                        ____________ Yes _____________ No

     B.   Has the Applicant, or any Affiliate, Intermediary, Subsidiary or Holding company ever
          had any license, permit or other authorization issued by a government agency in this state
          or any other jurisdiction, denied, suspended or revoked in last ten year period?

                                                        ____________ Yes _____________ No

          If yes, use Exhibit 9 to provide the following information for each license, permit or
          other authorization applied for and license or certificate denied, suspended or revoked.




10. CONTRIBUTIONS AND DISBURSEMENTS
     A.   During the last ten year period, has the Applicant, or any Affiliate, Intermediary,
          Subsidiary or Holding company, director, officer, or employee or any third party acting
          for or on behalf of the corporation made any bribes or kickbacks or made any payments
          alleged to have been bribes or kickbacks to any employee, company or organization to
          obtain favorable treatment?
                                                            ___________ Yes _________ No

     B.   Has the Applicant, or any Affiliate, Intermediary, Subsidiary or Holding company,
          director, officer or employee or any third party acting for or on behalf of the corporation
          made any bribes or kickbacks or made any payments alleged to have been bribes or
          kickbacks to any government official, domestic or foreign to obtain favorable treatment
          in the last ten year period?
                                                             ___________ Yes _________ No


     C.   In the last ten (10) years, Applicant, or any Affiliate, Intermediary, Subsidiary or Holding
          company has the maintained any bank account, domestic or foreign, not reflected on the
          Applicants books or records?
                                                              ___________ Yes _________ No




                                               13
D.   During the last ten year period, has the Applicant, or any Affiliate, Intermediary,
     Subsidiary or Holding company, maintained any numbered accounts or any account in
     the name of a nominee for the Applicant?
                                                        ___________ Yes _________ No

     If yes, use Exhibit 10 to provide the following information for any present or former
     directors, officers, employees or third parties who would have knowledge or information
     concerning the questions above referenced questions answered affirmatively under this
     item.




                                        14
EXHIBIT SECTION




       15
EXHIBIT 1a INCORPORATORS/FOUNDERS

Last Name                                                   First Name                                 Middle Name                       Suffix (Jr., Sr, etc.)


Occupation                                                                    Title


Address Line 1                                                                Address Line 2

City                                                                          State/Province                             Postal Code

Country                                                                       email address                              Phone number

Multi-Jurisdictional Personal History Disclosure Form Attached                                                           __ Yes ___ No
Principle Employee Form – Maryland Supplement To Multi-jurisdictional Personal History Attached                          __ Yes ___ No

Last Name                                                   First Name                                 Middle Name                       Suffix (Jr., Sr, etc.)


Occupation                                                                    Title


Address Line 1                                                                Address Line 2

City                                                                          State/Province                             Postal Code

Country                                                                       email address                              Phone number

Multi-Jurisdictional Personal History Disclosure Form Attached                                                           __ Yes ___ No
Principle Employee Form – Maryland Supplement To Multi-jurisdictional Personal History Attached                          __ Yes ___ No

                                                                * If necessary, copy exhibit and attach to application




                                                                                                                                         Initials: _____________




                                                                                      16
EXHIBIT 1b: OTHER NAMES AND ADDRESSES OF CORPORATION (Presently Used)


      NAME AND STREET                        CITY                                           STATE   ZIP




                                        * If necessary, copy exhibit and attach to application



                                                                                                    Initials: _____________




                                                            17
EXHIBIT 1c: ALL ADDRESSES OF APPLICANT

Address specific use


Address Line 1                                         Address Line 2

City                                                   State/Province                        Postal Code

Country                                                email address                         Phone number


Address specific use


Address Line 1                                         Address Line 2

City                                                   State/Province                        Postal Code

Country                                                email address                         Phone number


Address specific use


Address Line 1                                         Address Line 2

City                                                   State/Province                        Postal Code

Country                                                email address                         Phone number




                                    * If necessary, copy exhibit and attach to application

                                                                                                            Initials: _____________




                                                             18
EXHIBIT 1d: OTHER NAMES AND ADDRESSES OF CORPORATION (Past 10 years)

Other Name (if applicable)


Address specific use


Address Line 1                                          Address Line 2                                          date at address

City                                                    State/Province                            Postal Code

Country                                                                            Phone number




Other Name (if applicable)


Address specific use


Address Line 1                                          Address Line 2                                          date at address

City                                                    State/Province                            Postal Code

Country                                                                            Phone number




                                     * If necessary, copy exhibit and attach to application


                                                                                                                     Initials: _____________




                                                              19
Exhibit 1e: RELATIONSHIP OF APPLICANT AND BUSINESS ENTITY




                                        * If necessary, copy exhibit and attach to application
                                                                                                 Initials: _____________




                                                            20
EXHIBIT 2: CURRENT DIRECTORS, PARTNERS, OFFICERS AND TRUSTEES

                                     Name, Home Address & Business Address of Director, Partner, Officer or Trustee
Last Name                               First Name                             Middle Name                                    Suffix (Jr., Sr,    Date of Birth
                                                                                                                              etc.)

Home Address Line 1                                                   Home Address Line 2

City                                                                  State/Province                                  Postal Code

Country                                                               email address                                   Contact number

Business Address Line 1                                               Business Address Line 2

City                                                                  State/Province                                  Postal Code

Country                                                               Business email address                          Business Contact number



                          Title/Position Held, Dates, Compensation (List Current Position first, then work backward)
Title/Position                From Date/To Date                           Annual Compensation               Structure of Compensation (i.e.
                                                                                                            Salary, wages, bonus, fees,
                                                                                                            commission etc.)




                                                        * If necessary, copy exhibit and attach to application
                                                                                                                                           Initials: _____________




                                                                            21
EXHIBIT 3: OWNERS OF APPLICANT

                                   Name, Home Address & Business Address of Owner
Last Name                 First Name                          Middle Name                              Suffix (Jr., Sr,   Date of Birth
                                                                                                       etc.)

Home Address Line 1                                  Home Address Line 2

City                                                 State/Province                             Postal Code

Country                                              email address                              Contact number

Business Address Line 1                              Business Address Line 2

City                                                 State/Province                             Postal Code

Country                                              Business email address                     Business Contact number

                             Explain Type, Terms and Conditions of Ownership




                                       * If necessary, copy exhibit and attach to application
                                                                                                                          Initials: _____________




                                                                22
EXHIBIT 4: CRIMINAL HISTORY

NAME OF CASE AND   NATURE OF CHARGE OR   DATE OF          NAME AND ADDRESS OF LAW                  DISPOSITON         SENTENCE      Name of
DOCKET NUMBER      COMPLAINT             CHARGE OR        ENFORCEMENT AGENCY OR                    (ACQUITTED,                      Director,
                                         COMPLAINT        COURT INVOLVED                           CONVICTED,                        Partner,
                                                                                                   DISMISSED, ETC.)                 Officer or
                                                                                                                                     Trustee




                                          * If necessary, copy exhibit and attach to application
                                                                                                                          Initials: _____________


                                                                    23
EXHIBIT 5: INVESTIGATIONS, TESTIMONY OR POLYGRAPHS


NAME AND ADDRESS OF COURT             NATURE OF PROCEEDINGS          WAS TESTIMONY            DATES ON WHICH    APPROXIMATE       Director, Partner,
OR OTHER AGENCY                       OR INVESTIGATION               GIVEN?                   TESTIMONY WAS    TIME PERIOD OF     Officer or Trustee
                                                                        (Yes or No)           GIVEN            INVESTIGATION




Type of Proceeding or Investigation




NAME AND ADDRESS OF COURT             NATURE OF PROCEEDINGS          WAS TESTIMONY            DATES ON WHICH    APPROXIMATE       Director, Partner,
OR OTHER AGENCY                       OR INVESTIGATION               GIVEN?                   TESTIMONY WAS    TIME PERIOD OF     Officer or Trustee
                                                                        (Yes or No)           GIVEN            INVESTIGATION




Type of Proceeding or Investigation




                                                  * If necessary, copy exhibit and attach to application

                                                                                                                                Initials: _____________



                                                                           24
EXHIBIT 6: EXISTING AND PAST LITIGATION

Name of case and docket number   Name and address of law court          Name of all parties involved in litigation   Nature of Claim(s) and the nature of any
                                 involved in litigation                                                              judgments if any




                                                     * If necessary, copy exhibit and attach to application

                                                                                                                                                Initials: _____________




                                                                              25
EXHIBIT 7: ANTITRUST, TRADE REGULATION AND SECURITIES JUDGMENTS; STATUTORY
                                    AND REGULATORY VIOLATIONS

Title Or Case And Docket Number       Name And Address Of Court Or Agency                      Date Of Offense




Nature Of Offense



Disposition of Action



Nature Of Judgment, Decree Or Order




Title Or Case And Docket Number       Name And Address Of Court Or Agency                      Date Of Offense




Nature Of Offense



Disposition



Nature Of Judgment, Decree Or Order




                                      * If necessary, copy exhibit and attach to application

                                                                                                        Initials: _____________



                                                               26
EXHIBIT 8: BANKRUPTCY OR INSOLVENCY PROCEEDINGS

Date Petition Filed Or Relief   Title Of Case And Docket Number          Name And Address Of Court Or Agency
Sought




Date Judgment Entered                                                    Name And Date Appointed Of Court Appointed Receiver, Agent Or Trustee




Nature Of Judgment Or Relief




                                                         * If necessary, copy exhibit and attach to application




                                                                                                                                             Initials: _____________



                                                                                  27
EXHIBIT 9: LICENSES - Gaming and Non-gaming (List Gaming Licenses first and Non-gaming Licenses second)

Type Of License Or   Name And Location Of   Application           Disposition (i.e.           Disposition Date   If Issued, Give Appropriate License, Permit
Permit               Governmental Agency    Number                Granted, Denied,                               Or Other Such Number And Expiration
                                                                  Pending Expired,                               Date. If Denied, Pending, Expired,
                                                                  Suspended, Revoked                             Suspended, Conditioned, Withdrawn Or
                                                                  Withdrawn etc.)                                Revoked, Provide Why




                                             * If necessary, copy exhibit and attach to application
                                                                                                                                      Initials: _____________


                                                                      28
EXHIBIT 10: CONTRIBUTIONS AND DISBURSEMENTS
Last Name                   First Name                                    Middle Name                     Suffix (Jr., Sr,   Date of Birth
                                                                                                          etc.)

Entity Name

Address Line 1                                              Address Line 2

City                                                        State/Province                        Postal Code

Country                                                     email address                         Contact number



Last Name                   First Name                                    Middle Name                     Suffix (Jr., Sr,   Date of Birth
                                                                                                          etc.)

Entity Name

Address Line 1                                              Address Line 2

City                                                        State/Province                        Postal Code

Country                                                     email address                         Contact number



Last Name                   First Name                                    Middle Name                     Suffix (Jr., Sr,   Date of Birth
                                                                                                          etc.)

Entity Name

Address Line 1                                              Address Line 2

City                                                        State/Province                        Postal Code

Country                                                     email address                         Contact number

                                         * If necessary, copy exhibit and attach to application
                                                                  29
     Initials: _____________




30
       APPLICANT’S REQUEST TO RELEASE INFORMATION
TO: _________________________________________________________________________
                                          (To be filled in by Commission)


FROM: _____________________________________________________________________
                                             (Applicant’s Printed Name)

The above-named entity is an applicant (hereinafter referred to as “Applicant” or “Company”) for a License
with the Maryland State Lottery Commission (“Commission”), whose principle office is located at 1800
Washington Boulevard, Suite ___, Baltimore, MD 21230. This document provides the Commission with the
necessary authorization to conduct investigations of the Company. It also provides the issuing agency with the
applicable request, consent, and release of information notifications (hereinafter referred to as “Authorization
and Notification ”) in connection pending with the Company’s Application with the Commission.

   The Applicant hereby gives its authorization and consent to the Commission, including but not limited to, its
    commissioners, employees, agents and designees (hereinafter collectively referred to as “Agent”), to
    conduct full investigations into the background and records of the Company in connection with its
    Application, and to make inquiries and request such information from other third parties as, in the sole
    discretion of the Commission or its Agent, is necessary to such investigation. The Applicant acknowledges
    and agrees that the Commission may conduct all or part of such investigations and reviews on its own
    accord or may enlist the services of other entities as its Agent to conduct these investigations. The
    Company even further authorizes the use of any such information in the course of the Commission’s
    investigation and evaluation of the Company’s Application.

The Company hereby authorizes the release of any and all information pertaining to the Company, whether it be
documentary or otherwise, as requested by the Commission or its Agent, provided that the Commission’s
representative certifies to the issuing agency that the Company has a Application pending before the
Commission. This Authorization and Notification requests any and all persons and every present or former
firm, company, corporation, governmental entity, association, institution, or other third party to whom this
request is presented having personal knowledge and opinions about the Company or knowledge or control of
any information, documents, records, correspondence, or data (including, but not limited to, criminal and
financial history and record information, i.e., account, note and general ledger), pertaining to the Company, to
reveal, furnish copies, and release to the Commission or its Agent, any and all information, opinions,
knowledge, documents, records or other data in their possession regarding the Company, whether of a
privileged or confidential nature or whether or not such information would otherwise be protected from the
disclosures by any constitutional statutory or common law privilege. Without limiting the previously described
authorization, the Company specifically authorize the release of information concerning gaming and gambling
activities related to video lottery terminals. The Company hereby authorizes all such persons to answer any
inquiries, questions, or interrogatories concerning the Company, which may be submitted to them by or on
behalf of the Commission.

In consideration for the issuing agency gathering and disclosing such information, the Company further
specifically waives absolutely any privileges it may have and confidential relationship of privacy positions that
may exist which may be applicable to any documents or information sought from the issuing agency pursuant to
this Authorization and Notification. The Company hereby release the Commission and its Agent, from any civil
or criminal liability whatsoever for seeking such requested information and for evaluating such information as it
relates to the Company’s Application. Moreover, the Company hereby discharges, saves, and holds harmless
the Commission and its Agent from any and all claims and damages, as well as any responsibility or liability of

                                                        31
every nature and kind, resulting from or arising out of the Commission’s investigation. In addition, the
Company hereby releases the issuing agency and its agents and employees, both individually and collectively,
from any and all liability for damages of whatever kind, which may at any time result because of compliance
with this Authorization and Notification and request and/or furnishing, inspecting, disclosing, and using such
opinions, knowledge, documents, records, or other data.

The Company waives all right to inspect or review any information compiled in reference to its Application.
The Company authorizes the Commission and its Agent to release copies of any and all information to any
agency or entity regulating the applicant or licensee to include, but not limited to: Maryland State Police, and
other law enforcement offices (police department or sheriff’s office) in the State of Maryland, Maryland
Attorney General’s Office, agencies of other states, the federal government and any foreign government or any
foreign or domestic entities.

The Company authorizes that a photocopy or facsimile copy of this Authorization and Notification, or any other
copy, be effective and accepted with the same authority, validity, and legality as the original instrument bearing
the signature of a Company officer or director, and the Company specifically waives any written authorized
request. The Company acknowledges and understands that this Authorization and Notification consists of a
two (2) page document that will become part of the Company’s Application.

This Authorization and Notification is limited to the Company’s Application or license with this Commission
and shall supersede and countermand any prior request or notification to the contrary by the Company. This
Authorization and Notification shall be valid for this application and any future investigations, reports or
updates that may be requested by the Commission.

The Company has read and fully understands the above consents and authorizations. By affixing a signature
below, the Company authorizes any duly noted representative of the Commission to request information about
the Company from entities for the purpose of determining the Company’s eligibility to obtain and retain a
license.

_____________________________                __________________________________________
          DATE                                              SIGNATURE OF APPLICANT

__________________________________           __________________________________________________
       WITNESS’ SIGNATURE                                  PRINT NAME OF APPLICANT

                                             _____________________________________________________
                                                               TITLE

The undersigned, a Notary Public in and for the County of ______________________, in the State of
_______________________, certifies that the above named individuals appeared in person, and before me,
either known to me or satisfactorily proven to be the individuals whose name subscribed to the within
instrument and signed the Authorization and Notification.

This _________ day of _________________________, 20_____, and to which witness my hand and seal.

                                      ____________________________________
                                                  Notary Public
                                      ________________________________
       Stamp or Seal                              Printed Name

                                      My commission expires _________________, 20_____
                                                       32
                 APPLICANT’S CONSENT, AUTHORIZATION &
                    ACKNOWLEDGEMENTS, & WAIVER
Please read this document carefully, then sign and date it in ink. Please print the following information:

                                                                                                      ____________
Applicant’s Full Business Name

                                                                                                      ____________
Street Address                   City                          State                  Zip

In order to determine the Company’s qualifications for a license, the above-referenced entity (hereinafter
referred to as “Applicant” or “Company”) understands, acknowledges, and consents that the Maryland State
Lottery Commission (“Commission”), including but not limited to, its commissioners, employees, agents and
designees (hereinafter collectively referred to as “Agent”) must make a thorough investigation of the
Company’s records and background. It is in the public’s interest that all relevant information concerning the
Company be disclosed to the Commission and that the Commission and its Agent obtain all necessary and
required acknowledgements concerning the Applicant’s consents, authorizations and acknowledgments, and
waivers (hereinafter referred to as “Acknowledgement”).

                                                   CONSENT

The Applicant hereby consents and acknowledges that the Commission or its Agent shall have the power and
authority, without notice and without warrant, to do any and all of the following act in accordance with the State
Government Article, § 9-1A et seq., of the Annotated Code of Maryland:

1.     Inspect any video lottery terminals, central monitor and control system, or associated equipment and
       software in, about, on, or around those premises;

2.     Inspect and examine all premises in which video lottery operations under this subtitle are conducted or
       any authorized video lottery terminals, central monitor and control system, or associated equipment and
       software designed, built, constructed, assembled, manufactured, sold, distributed, or serviced, or in
       which records of those activities are prepared or maintained;

3.     Seize summarily and remove from those premises and impound, or assume physical control of any video
       lottery terminals, central monitor and control system, or associated equipment and software for the
       purposes of examination and inspection;

4.     Inspect, examine, and audit books, records, and documents concerning a licensee’s video lottery
       operations, including the financial records of a parent corporation, subsidiary corporation, or similar
       business entity; and

5.     Seize, impound, or assume physical control of books, records, ledgers, cash boxes and their contents, a
       counting room or its equipment, or other physical objects relating to video lottery operations.

                          AUTHORIZATION & ACKNOWLEDGEMENT


                                                         33
The Applicant hereby consents and acknowledges that the Commission and its Agent are authorized to conduct
investigations into the Company’s background and records using whatever legal means it deems appropriate.
The Applicant understands that the Commission and its Agent will conduct full, complete, and comprehensive
investigations to determine the accuracy of all information gathered. The Commission and its Agent reserve the
right to investigate all relevant information and facts to its satisfaction.

The Applicant understands that by signing this document, a background investigation including, but not limited
to, criminal history and credit reports, will be conducted by the Commission. The Commission discloses to the
Applicant that criminal, civil and financial investigative background reports will be obtained for the purpose of
determining the Company’s qualifications and eligibility for a license as required by law and to consider the
Company’s financial responsibility, stability, and integrity.

The Applicant understands and acknowledges that persons and entities requested to provide information to the
Commission or its Agent must be given authorization by the Applicant to release such records and information.
The Applicant understands and agrees that the results of such investigations and its conclusion may be used by
the Commission and its Agent – whether orally or in writing - in order to process the Company’s Application.

The Applicant hereby understands, acknowledges, and consents that the Commission and its Agent, without
exception, will examine documents, records, and data from foreign and domestic sources whether through
public and private channel, including but is not limited to, credit bureaus, motor vehicle records and
investigations, reports from federal, state and local gaming and gambling clients; professional associations;
certification/licensing boards and commissions; criminal and civil courts and administrative tribunals; police
departments and bureaus; banks, financial and lending institutions; bonding, surety and insurance companies;
governmental agencies and units; corporations, employers, and references, or any other entity deemed necessary
to release any information the Commission and its Agent may require in connection with its investigations.

   The Applicant understands and acknowledges that the Commission and its Agent may obtain information
    pursuant to such investigations through personal interviews with acquaintances, business associates and
    other persons who may have knowledge as to the Company’s background and records. The Applicant
    further understands and acknowledges that inquiry into the Company’s charter and bylaws, public records,
    registrations and licenses, and depositions and transcripts may be relevant to the Commission’s evaluation
    of the Company’s qualification and eligibility.

The Applicant acknowledges and consents that a criminal background investigation and report will be requested
and used by the Commission and its Agents for the purpose of reviewing and evaluating the Company’s
Application, and possibly for the issuance and continuation of a license. The Applicant understands and agrees
that the results of this background investigation and report, as well as the conclusions drawn therefore from by
the Commission and its Agent, may prove unfavorable to the Company.

If a license is approved, the Applicant acknowledges and authorizes that the Commission and its Agent, as well
as its successors and assigns, may obtain the above mentioned background information about the Company at
any time and on an ongoing basis in connection with this application process or for any one or more of the
following reasons: (1) issuing and reviewing the license; (2) taking administrative or regulatory action on the
license; or (3) any other legitimate and lawful purpose associated with the license. The Applicant agrees to
cooperate with any such investigations by the Commission.

The Applicant understands and acknowledges that falsification of information shall constitute an immediate
denial of a Application, and/or suspension or revocation of a license. Any misleading or incorrect statements,
omissions whatsoever, including any failure to disclose any criminal conviction or any threatened or actual
debarment, exclusion or other ineligibility notice for participation in gaming and/or gambling activities, may
                                                       34
remove this Application from further consideration by the Commission and, if licensed, may cause such license
issued by the Commission to be suspended or revoked. Such actions may also subject the Applicant to civil and
criminal penalties as proscribed by law.

Background Investigations
The Applicant hereby understands and acknowledges that the Commission and its Agent must initiate
investigations into the backgrounds and records of any Applicant or the Applicant's officers, principals,
investors, owners, employees, subcontractors, or subcontractors' officers, principals, owners, and employees, or
any other associates of the Applicant it deems appropriate. Such background investigations may include
fingerprint identification by the Maryland State Police, the Federal Bureau of Investigation, or any foreign
investigative service with the fee for such investigation to be paid by the Applicant. The Applicant will be
billed by the Commission and its Agent for such background investigations, including travel and per diem
expenses. By submitting an Application to the Commission, the Applicant understands and agrees that the
Applicant or Licensee shall pay such invoices within thirty (30) days of receipt.

The Applicant understand and agrees that the criminal history record files contain records of arrests which may
have resulted in a disposition other than a finding of guilty (i.e. dismissal of charges or charges that resulted in a
finding of not guilty). The Applicant further understand and agrees that the information may contain listings of
charges that resulted in a suspended sentence even though the Company successfully completed the conditions
of probation or charge was later discharged or expunged. The Applicant acknowledges and authorizes that this
type of information may be released to the Commission and its Agent even though this record is designated as
non-public.

In order to facilitate the background investigations, each Applicant, including the parent or subsidiary of each
Applicant must complete the documentation required by the Commission. The Commission and its Agent
reserve the right to require additional background information from the Company.

The Successful Applicant agrees that, during the term of the license and any renewal thereof, the Company shall
be obligated to provide such information about its officers, directors, employees and owners, as well as all
information about its subcontractors' officers, directors, employees and owners, as the Commission may
prescribe. The Successful Applicant also agrees that the Commission and its Agent may conduct further
background investigations of such persons at the expense of the Successful Applicant.

Financial Soundness
The Applicant must provide evidence of financial responsibility, stability, and integrity for performance of any
license and must demonstrate the ability to finance the project described in its Application submission if such
information is required. The Applicant specifically acknowledges and consents that the Commission may run
and obtain a consumer credit report in conjunction with its investigation. This report may contain information
bearing on the Company’s credit worthiness, credit standing, and credit capacity.

If the person to whom this request is presented is a brokerage firm, bank, savings and loan, or other financial
institution or an officer of the same, the Applicant hereby authorizes and requests that the Commission and its
Agent be permitted to review and obtain copies of any and all documents, records or correspondence pertaining
to the Company, including but not limited to past loan information, notes co-signed by the Company, checking
account records, savings deposit records, safe deposit box records, and general ledger folio sheets.

The Applicant understands and acknowledges that it shall submit with its Application proof of financial
responsibility, stability, and integrity acceptable to the Commission:

(a)    if the Applicant is the subsidiary of a parent corporation, a statement by such parent corporation; and
                                                         35
(b)     copies of any all documents requested by the Commission.
The Applicant understands and consents that the Commission and its Agent reserve the right to require any
additional information necessary to determine the financial responsibility, stability, and integrity of the
Applicant or Licensee. If a license is granted, the Applicant understands and agrees that it must include a
certification to the Commission of a change in financial condition during the first year of operation. If an
Applicant experiences a substantial change in its financial condition during the period prior to the issuance of
any license, or if the Successful Applicant experiences a substantial change in its financial condition during the
term of its license or any extension thereof, the Commission and its Agent must be notified of the change in
writing at the time the change occurs or is identified. The Applicant acknowledges that failure to notify the
Commission of such substantial change in financial condition will be sufficient grounds for denial of the
Application or revoking the license.

                                  SPECIAL POWER OF ATTORNEY
The Applicant hereby makes, constitutes, and appoints any duly appointed agent of the Commission, the
applicant’s true and lawful Attorney-in Fact for the Applicant in its name, place, stead and on its behalf and for
its use and benefit;

   (a)     To request, review, copy, sign for, or otherwise act for investigative purposes with respect to
           documents and information in the possession of the person to whom this request is presented as
           Applicant might;

   (b)     To name the person or entity to whom this request is presented and insert that person’s name in the
           appropriate location in this request; and

   (c)     To place the name of the agent presenting this request in the appropriate location on this request;

The Applicant grants to said Attorney-in-Fact full power and authority to do, take, and perform all and every act
and thing whatsoever, requisite, proper, or necessary to be done in the exercise of any of the rights and powers
herein granted, as fully to all intents and purposes as applicant might or could do if personally present, with full
power of substitution or revocation, hereby ratifying and confirming that all that said Attorney-in-Fact, or his
substitute or substitutes, shall lawfully do or cause to be done by virtue of this power of attorney and the rights
and powers herein granted.

                                                  WAIVERS
The Applicant understand and agrees that these documents and records may contain negative information about
the Company; therefore the Applicant agrees to save and hold harmless the Commission and its Agent, or any
entity acting on its behalf, as well as its commissioners, director, employees, from any and all claims and
liability for all damages including but not limited to consequential, exemplary, special, indirect, incidental or
punitive damages, loss of profit or loss of business opportunity including reasonable attorneys’ fees arising
through the investigation of the Company’s background and records. The Commission and its Agent shall not
be held liable for inaccurate information, if a good faith effort has been made to verify and substantiate all
information and facts.

The Applicant does, for itself, its heirs, executors, administrators, successors, and assigns, hereby release,
remise, and forever discharge the person to whom this request is presented, and the agents and employees from
all and all manner or actions, causes of action, suits, debts, judgments, executions, claims, and demands
whatsoever, known or unknown, in law or equally, which the Applicant ever had, now has, may have, or claims
to have against the person to whom this request is being presented or his agents or employees arising out of or
by reason of complying with the request.
                                                        36
The Applicant agrees to indemnify and hold harmless the person to whom this request is presented and its
agents and employees from and against all claims, damages, losses, and expenses, including reasonable
attorneys’ fees arising out of or by reason of complying with this request.

The Commission and its Agent will keep such investigations confidentiality except where disclosure is required
by law, or by the final ruling of a court, pursuant to the laws of the State of Maryland or the United States of
America, or if such information has been made public by a third party.

                       APPLICANT’S STATEMENT & CERTIFICATION
The Applicant authorizes the investigations of any and all statements contained in this Acknowledgement as
well as the Company’s Application as may be necessary in arriving at a licensing decision. The Applicant
understands that the Application is not intended to be a license. The Applicant certifies that the information
given in its Application is an accurate statement of facts about the Company. By signing this document, you
acknowledge the Company’s awareness that any false or misleading statements, omissions, or failure to disclose
information may disqualify the Company’s Application.

This is to certify that the Company has filed with the Commission an application for a license. The Applicant
understands that it is seeking the granting of a privilege and acknowledges that the burden of proving its
qualifications for a favorable determination is at all times on the Applicant. The Applicant accepts any risk of
adverse public notice, embarrassment, criticism, or other action of financial loss, which may result from action
with respect to its application.

The Applicant certifies that it has completed this Acknowledgement of its own free will, without promises of
immunity, threats, coercion, or duress. The Applicant certifies that this document shall remain valid,
enforceable for the entire term of the license, and as proscribed by law.

_____________________________               __________________________________________
          DATE                                             SIGNATURE OF APPLICANT

__________________________________          __________________________________________________
       WITNESS’ SIGNATURE                                 PRINT NAME OF APPLICANT

                                            _____________________________________________________
                                                              TITLE
                                                 NOTARY
The undersigned, a Notary Public in and for the County of ______________________, in the State of
_______________________, certifies that the above named individuals appeared in person, and before me,
either known to me or satisfactorily proven to be the individuals whose name subscribed to the within
instrument and signed the Authorization and Notification.

This _________ day of _________________________, 20_____, and to which witness my hand and seal.

                                     ____________________________________
                                                 Notary Public
                                     ________________________________
       Stamp or Seal                             Printed Name

                                     My commission expires _________________, 20_____
                                                      37
38
               APPLICATION CHECKLIST – VIDEO LOTTERY FACILITY
                               APPLICATION
 Use the following list to indicate with an X the exhibits that are attached with this application. All attachments are Mandatory and
need to be submitted. If a question, exhibit or addendum is not applicable, indicate “Not Applicable” and state why it is not
applicable in the exhibit. If any item is missing or not filed according to these directions, the application will be considered
incomplete and will not be processed.

   EXHIBIT                                     EXHIBIT DESCRIPTION                                       X IF ATTACHED
   NUMBER                                                                                                (ALL FORMS ARE
                                                                                                         MANDATORY)
       1a           Incorporators/Founders
       1b           Other names and addresses of the applicant
       1c           All Current Addresses of Applicant and where doing business
       1d           Other names and addresses of the corporation (Past 10 years)
       1e           Relationship of Applicant and Business Entity
        2           Current Directors, Partners, Officers, Trustees and Compensation
        3           Owners of Applicants
        4           Criminal History
        5           Investigations, Testimony or Polygraphs
        6           Existing and Past Litigation
        7           Antitrust, trade regulations and securities judgments; statutory and
                    regulatory violations
        8           Licenses
        9           Bankruptcy or insolvency proceedings
       10           Contribution and Disbursements
     -------        Applicant’s Request To Release Information
     -------        Applicant’s Consent, Authorization & Acknowledgements, &
                    Waiver
     -------        Request for Transcript of Tax Return




                                                                                                               Initials: _____________




                                                                  39
                                                      APPENDICES
Appendices are attachments you are to provide or create and do not contain corresponding questions, exhibits or charts. Each
document provides as an appendix shall be in provided in a tabbed manner and presented in the same order as listed below. If a
appendix is not applicable, indicate “Not Applicable” and state why it is not applicable. All information shall be provided in
addition to the exhibits that are to be provided.
   Appendix                                    Appendix Description                               X IF ATTACHED
                                                                                                  (ALL FORMS ARE
                                                                                                  MANDATORY)
       1           Description of Existing Litigation. Provide this information in
                   addition to both Exhibit 6.
       2           Audited Financial statements for the last five years, including
                   the Applicants last fiscal year. If audited financial statement
                   do not exist, then provide unaudited financial statements
       3           Annual reports for the last five years
                   Description of Security Options.
       4
       5           Description of Existing Litigation. Description of any settled
                   or closed litigation against the Applicant for the past three (3)
                   years. Also describe any existing or settled or closed litigation
                   for the past three (3) years for any holding, intermediary,
                   subsidiary or affiliate. A description of any judgments against
                   Applicant, holding, intermediary, subsidiary or affiliate for the
                   past five (5) years. Describe if any judgments were covered
                   by insurance and if so the insurance company. Provide this in
                   addition to Exhibit 6 & 9.
       6           Audited Financial statements for the last five years, including
                   the Applicants last fiscal year. If audited financial statement
                   do not exist, then provide unaudited financial statements.
       7           Annual reports for the last five years
       8           Annual reports prepared on the SEC’s form 10K for the last 5
                   years.
        9          A copy of the last quarterly unaudited financial statement
       10          Copy(ies) of any interim reports
       11          A copy of the last definitive Proxy or information statement
                   (SEC)
       12          A copy of all registration statements for the last five years
                   filed in accordance with the Securities Act of 1933
       13          Copies of all other reports prepared in the last five years by
                   independent auditors of the corporation
       14          Certified copies of the Articles of Incorporation, Charter and
                   By-laws, and all amendments and proposed amendments
       15          Current ownership table of organization
       16          Copies of 1120 forms and 941 forms filed with the IRS in the
                   last five years.
       17          Copies of IRS 5500 form filed in the last 5 years.

                                                                                                          Initials ________

                                                                40
                                   APPENDICES (CONT)



Appendix                        Appendix Description                           X IF ATTACHED
                                                                               (ALL FORMS ARE
                                                                               MANDATORY)
  18       If Applicant has held a gaming license in another jurisdiction,
           provide a letter of reference from the gaming or casino
           enforcement or regulatory agency with the Applicant,
           specifying the experiences of the agency with the applicant,
           the applicant’s associates and the applicant’s gaming
           operation.
  19       Provide a chart of existing vendors including the name,
           address, phone and tax identification number of the vendor,
           type of good and/or services provided by the vendor, total
           amount of business with vendor in the past twenty four (24)
           months.
  20       Along with the description provided in Exhibit 22, provide the
           nature and results of any other material reorganization,
           readjustment or success of the applicant, holding,
           intermediary, subsidiary or affiliate. Also describe the
           acquisition or disposition of any material amount of assets
           otherwise then in the normal course of business and any
           material change in the way business was conducted by the
           applicant, holding, intermediary, subsidiary or affiliate because
           of such a proceeding.




                           LEFT BLANK INTENTIONALLY




                                                  41
     Initials ________




42

				
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