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CASINO SERVICING ENTITY NON-GAMING RELATED LICENSE APPLICATION UNITED STATES VIRGIN ISLANDS CCC:NGRLE. I REV.2/2016 CASINO SERVICING ENTITY NON GAMING RELATED APPLICATION INSTRUCTIONS 1. This application shall be completed by any entity doing business with casino licensees or casino applicants in the U.S. Virgin Islands. This form shall also be completed by related affiliates to any entity so directed by the U.S.Virgin Islands Casino Control Commission. 2. Applicant entity agrees that any license which may hereafter be granted to said individual or business organization is predicated upon the statements and answers herein contained and that for any materially false or misleading statement or answer, said license may be revoked. Entity's background will be investigated by the U.S. Virgin Islands Casino Control Commission and the Division of Gaming Enforcement, Department of Justice. 3. False information or lack of total disclosure on any aspect of this application may result in license denial. 4. Information requests must be answered completely. Information must be provided as of the date of the application unless otherwise specified. 5. All entries on this form, except signatures, must be typed or block printed in black ink. If your application is not legible, it will not be accepted. 6. Where a response to a particular question is provided fully in a response to another question elsewhere in this application, reference your answer to that other response. If a partial response is given elsewhere, indicate the reference and complete the requested information. 7. If a question is inappropriate or not applicable to the type of business being conducted, indicate "N.A." on the application. 8. If you need additional space to answer any question(s), attach an additional sheet if necessary. Be sure to indicate the number of the question you are answering. 9. For purposes of this application, "enterprise" or "entity" shall be defined to include any corporation, association, operation, firm partnership, trust, or other form of business association, as well as a natural person. 10. Submit an original and one (1) copy of this entire application form to the U.S. Virgin Islands Casino Control Commission. 11. Once filed, you may not withdraw your application without the permission of the U.S. Virgin Islands Casino Control Commission. 12. We recommend that you keep a copy of your completed application for your records. 13. An appropriate individual must sign the accompanying Verifying Affidavit, Release Authorization and Release of All Claims in the presence of a notary public and have the signature notarized. 14. The majority of questions and requirements of this application are self-explanatmy. Should the applicant need further explanation of any aspect of this application, applicant should contact the U.S. Virgin Islands Casino Control Commission. Rev. 2/16 2 Virgin Islands Casino Control Commission 3005 Orange Grove Christiansted, VI 00820-3005 (340) 718-3616 ext. 240 • (340) 718-3136 fax info@casinocontrolcommission.vi CASINO SERVICING ENTITY NON-GAMING RELATED LICENSE APPLICATION CHECKLIST  Casino Servicing Entity Non-Gaming Related Application. Entity must answer every question completely  License Application Conditions, Verifying Affidavit, Release Authorization must be notarized  Item 5 – Qualifiers are identified.  Item 6 – Financial Information are provided. ALL QUALIFIERS MUST COMPLETE PHD FORM -2  Personal History Disclosure Form 2. Applicant must answer every question completely  Statement of Truth, Release of all Claims, and Release Authorization must be notarized THE FOLLOWING DOCUMENTATION ARE REQUIRED FOR INITIAL APPLICATION  Fingerprint card  VIPD Background check  2 passport size pictures  2 Government issued I.D. (i.e., V.I. Driver’s license, Passport and/or Voter’s I.D.)  Birth Certificate  Naturalization Document or U.S. Passport  Tax documents (last 3 years) THE FOLLOWING DOCUMENTATION ARE REQUIRED FOR RENEWAL APPLICATION  Completed application for license renewal  Personal History Disclosure Form 2 – Renewal. Applicant must answer every question completely  Fingerprint card  Background check  2 passport size pictures Virgin Islands Casino Control Commission Henry E. Schjang – Special Assistant  2 passport size pictures  Tax documents (last 3 years) CASINO REGISTRATION FEES:  Initial: $1,800.00  Renewal: $1,600.00 A. CHECK THE APPROPRIATE SPACE: For VICC use only _ This form is submitted as an initial application for a Casino Service Industry Non -Gaming Related License. This form is submitted as an application for renewal of a Casino Service Industry Non-Gaming Related License. B. NAME OF ENTERPRISE (Note: State the name as it appears on the certificate of incorporation, charter, etc.) D. CONTACT PERSON: (List name of person to be contacted in reference to these forms.) NAME TITLE E. PRINCIPAL BUSINESS ADDRESS OF ENTERPRISE: (Be sure to include the street location of the enterprise, should your mailing address be different). PRINCIPAL ADDRESS: MAILING ADDRESS: TELEPHONE: _(___) ______ _ FAX:_(___) ________ _ F. STATE ADDRESS FROM WHICH THE ENTERPRISE IS OR WILL BE CONDUCTING ANY BUSINESS AS PART OF AN AGREEMENT WITH THE CASINO HOTEL. Rev. 2/16 3 ITEM 1 - PRIOR NAMES AND ADDRESSES OF THE ENTITY A. List all other names under which the entity has done business during the last five years. B. List dates and other addresses from which the entity has done business within the last five years. ITEM 2 - DESCRIPTION OF ENTITY A. Specify the business form of this entity (state whether it is a corporation, partnership, trust, joint venture, sole proprietorship or otherwise). B. Please submit, as "EXHIBIT 2-B", a copy of the certificate of incorporation, charter, by-laws, partnership agreement, trust agreement or other basic documentation of the entity, if any. C. Please submit, as "EXHIBIT 2-C", a copy of current business license or application for a business license. D. Please state the type of goods or services being provided to the casino industry. E. Please state the nature of business of your entity. ITEM 3 - AGREEMENTS A. If the entity has entered into any written agreements with casino licensees or casino applicants indicate here the number of such written agreements. ___ _ Attach to this form, "as EXHIBIT 3-A," a copy of agreements. Rev. 2/16 4 B. If the entity has entered into any unwritten agreements or purchase order business with casino licensees or applicants describe below the terms of each unwritten agreement, including in said description the expected duration and terms of compensation of each such agreement. C. Are or were any agreements between this entity and casino licensees or casino applicants any way subject to or conditioned upon any other agreement between the casino licensees and casino applicants and either this entity or any other entity whatsoever? __ Yes No If yes, identify each such agreement, explain the relationship and name the entity. D. Are or were any agreements between this entity and any casino licensee or casino applicant contingent upon other agreements between the entity and its suppliers, vendors or subcontractors? Yes No If yes, identify the said suppliers, vendors or subcontractors and identify the relationship between that agreement and any other agreement with a casino hotel. E. Are any of the suppliers, vendors or subcontractors of the entity, holders of any securities of the entity or creditors as to any long or short term debt of the entity? __ Yes __ No If yes, identify the said supplier, vendors or subcontractors, the nature of the interest or debt, and the amount thereof. ITEM 4 - GOVERNMENT AL REGULATION A. Is the entity subject to regulation by a public agency in this Territory or in any other jurisdiction? __ Yes No Rev. 2/16 5 ___ __ __ _ _ _ If yes, identify the public agency and it location, and describe the nature and extent of the regulation as it affects this entity (for example control of rates, individual qualifications, criminal records, etc.) B. During the last five year period, has the entity ever had any license or certificate issued by a government agency in this Territory or any other jurisdiction denied, suspended or revoked? Yes No If yes, state the name and nature of the license or certificate denied, suspended or revoked, the name and location of the government agency taking such action, the date of each such action and the reasons therefore in the following tabular form: TYPE OF LICENSE NAME AND LOCATION OF ACTION DATE REASON OR CERTIFICATE GOVERNMENTAL AGENCY TAKEN ITEM 5 - QUALIFIERS Please indicate all persons or entities in your enterprise that correspond to the sub-items listed below. If any of the sub-items (a) through (I ) do not apply, please indicate "Does Not Apply" directly on this form. For those listed below, complete the information on the next page in the format indicated. NOTE: A PERSONAL IDSTORY DISCLOSURE FORM 2B MUST BE COMPLETED BY EVERY PERSON NOTED IN ITEM 5 A THROUGH I BELOW. IN ADDITIOIN, THE COMMISSION MAY, IN ITS DISCRETION, ORDER ADDITIONAL PERSONS ASSOCIATED WITH THE ENTITY TO FILE SUCH A FORM IF IT APPEARS THAT SUCH PERSONS SHOULD BE QUALIFIED IN ORDER TO EFFECTUATE THE PURPOSES OF THE CASINO CONTROL ACT. A. All persons who will act as sales representatives or otherwise regularly engage in the solicitation of business from a casino hotel. B. All persons who have or will sign any agreement with a casino hotel. C. All immediate supervisors of each person described in Paragraph A. Rev. 2/16 6 _______ ___ _____ D. All persons responsible or in charge of the office. E. All officers of the entity. F. All directors or trustees of the entity. G. All partners, whether general, limited or otherwise. H. The sole proprietor, if the entity is a sole proprietorship. I. All beneficial owners of ten or more percent of the outstanding voting securities of the entity, whether such owners are themselves an entity or natural persons. If an entity is listed as an owner, a completed Casino Servicing Entity Form Non-Gaming Related must be submitted. For every person or entity noted in items 5 A through I on the previous page, provide the information requested in the following tabular form: NAME DATE OF HOME ADDRESS TITLE, POSITION ( %OF BffiTH ASSOCIATION OWNERSHIP WITH THE ENTITY Should you require additional space, attach a separate sheet in the tabular form and label it ITEM 5-A, 5-B, etc. ITEM 6-FINANCIAL INFORMATION A. If the entity has audited financial statements prepared, submit two (2) copies of the most recently prepared statement and auditor's report. Mark both the statement and report as "ITEM 6-A." B. If the entity does not normally have its financial statements audited, submit two (2) copies of the most recently prepared unaudited financial statement and mark such statement as "ITEM 6-B." (If the entity has neither an audited or unaudited financial statement prepared, please note same below this paragraph.) C. Please include two (2) copies of the most recently filed federal and state tax returns, in full, including all attachments, schedules and extension requests. Mark each return and schedule as ITEM 6-C." Rev. 2/16 7 D. Has the entity had any petition under any provision of the Federal Bankruptcy Act or under any State insolvency law filed by or against it in the last five year period? __ Yes No If yes, provide the followin2 information in tabular form: COURT NAME COURT LOCATION TYPE OF PETITION DATE FILED OFFICIAL NAME OF CASE E. Has the entity sought relief under any provision of the Federal Bankruptcy Act or under any State insolvency law in the last five year period? Yes No If yes, provide the followin2 information in tabular form: COURT NAME COURT LOCATION NAME OF RELIEF SOUGH1 DATE FILED CASE F. Has any receiver, fiscal agent, trustee, reorganization trustee or similar officer been appointed, in the last five year period, by a court for the business or property of the entity? _Yes _No If yes, provide the followin2 information in tabular form: NAME OF PERSON DATE APPOINTED COURT REASON APPOINTED Rev. 2/16 8 _ _ LICENSE APPLICATION CONDITIONS By the signing of this application, the applicant entity acknowledges that if a license be granted, it will become the duty of the applicant/licensee to file with the U.S. Virgin Islands Casino Control Commission ("Commission") such reports and financial data as may be required by Territorial Statute or by such rules and regulations as the Commission has adopted or may hereafter adopt, and to make such payments and/or fees as may be required by law. The aforementioned duty shall continue for the entire term (duration) of the license. If the applicant/licensee fails to abide by these requirements, the applicant/licensee shall incur the penalties set forth in the U.S Virgin Islands Code or in such rules and regulations as said Commission has adopted or may hereafter adopt. If a license be issued, the applicant/licensee agrees to abide by and comply with the provisions of Title 32 of the Virgin Islands Code and any rules and regulations heretofore and hereafter promulgated by the Commission. Applicant entity verifies that all exhibits, statements, reports, papers, data, etc. submitted pursuant to this application are true, complete and current. The applicant entity additionally agrees to THEREAFTER provide the Commission with full description of any significant operational change in any of the aforementioned exhibits, statements, reports, papers, data, etc. as said change occurs. Applicant entity hereby consents to all inspections, searches and seizures and the supplying of handwriting exemplars as authorized by 32 VIC 432(c). Applicant entity agrees that any license which may hereafter be granted to said individual or business organization is predicated upon the statements and answers herein contained, which may be subject to verification by the Commission and that for any false or misleading statement or answer said license may be revoked. I/We have read the application, attached instructions and above paragraphs, and agree to the conditions as set forth. Applicant Entity: -------------- (PrintName) (Signature) Rev. 2/16 9 SIGN VERIFYING AFFIDAVIT TERRITORY OF THE UN1TED STATES VIRGIN ISLANDS) ) SS: DISTRICT OF ST. CROIX _______________ , the _______________ of the applicant (Name) (Title) entity, being duly sworn according to law, on his/her oath, depose applicant entity, and that the above statements are true and correct to the best of his/her knowledge and belief, and that this statement is executed with the knowledge that any misrepresentation or failure to reveal information requested may be deemed sufficient cause for the refusal to issue, or revocation of, a license. Further, that he/she is voluntarily submitting this statement and understands that misleading statements may subject him/her to criminal or other sanctions or punishment. (Name of Applicant Entity) By (Signature) (Title) SUBSCRIBED and SWORN to before me this __ day of ______ __ _ Notary Public Commission Expiration Date SEAL Rev. 2/16 10 SIGN RELEASE AUTHORIZATION To All Courts, Probation Departments, Selective Service Boards, Employers, Educational Institution, Banks, Financial and Other Such Institutions, and All Governmental Agencies - federal, state and local, without exception, both foreign and domestic. I,---------------- have authorized the U.S. Virgin Islands Casino (Print Name) Control Commission to conduct an investigation in to the background of the said applicant entity. Therefore, you are hereby authorized to release any and all information pertaining to the said applicant entity, documentary or otherwise, as requested by any appropriate employee, agent or representative of the U.S. Virgin Islands Casino Control Commission. This authorization shall supersede and countermand any prior request or authorization to the contrary. A photostatic copy of this Authorization will be considered as effective and valid as the original. Signature SUBSCRIBED and SWORN to before me on this __ day of ________ _ Notary Public Commission Expiration Date SEAL Rev. 2/16 11 SIGN RELEASE OF ALL CLAIMS The undersigned has filed with the U.S. Virgin Islands Casino Control Commission an application for a license. In consideration of the assurance by the Commission that no vote on said application will be taken except after deliberate, intensive and thorough investigation of the undersigned, including but not limited to background, family, associates and finances, the undersigned does for myself, my heirs, executors, administrators, successors and assigns, hereby release, remise and forever discharge the Government of the U.S. Virgin Islands, its instrumentalities and agents, including the U.S. Virgin Islands Casino Commission, its members, agents, and employees, from any and all manner of actions, causes of actions, suits, debts, judgments, executions, claims and demands whatsoever, known or unknown, in law or equity which the undersigned ever had, now has, may have, or claim to have, against any or all of said entities or individuals arising out of or by reason of the processing of the license or the investigations or hearings or other action relating to the undersigned's application for a license. I, the undersigned, having read this release, execute it voluntarily with full knowledge of its significance. Signature Subscribed and sworn before me On this __ day of ________ _ Notary Public Commission Expiration Date SEAL Rev.2/16 12 SIGN