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MULTI JURISDICTIONAL PERSONAL HISTORY DISCLOSURE FORM Virgin Islands Casino Control Commission 3005 Orange Grove Christiansted, St. Croix United States Virgin Islands 00820 Telephone: 340-718-3616 • Fax: 340-718-3136 Initial Application: Additional Documentation required to be submitted with your Application: 1. Finger print card 2. Background check 3. 2 passport size pictures 4. 2 Government issued I.D. (i.e. V.I. Driver's license, Passport and/or Voter's I.D.) 5. Birth Certificate 6. Social Security Card 7. Naturalization Document or U.S. Passport 8. Offer letter 9. Tax documents (last 3 years) 10. High School Diploma Renewal Application: 1. Finger print card 2. Background check 3. 2 passport size pictures 4. 2 Government issued I.D. (i.e. V.I. Driver's license, Passport and/or Voter's I.D.) 5. Tax documents (last 3 years) This application is designed to allow applicants for casino/gaming qualification to complete one form that is acceptable to several jurisdictions. The questions contained in this form have been designed to satisfy the variety of filing and informational requirements of the different jurisdictions that have agreed to accept this form as an MULTI JURISDICTIONAL PERSONAL HISTORY DISCLOSURE FORM application for qualification. Each jurisdiction accepting this form may require unique information and documentation that is not requested in this standardized form. Prior to completing this form, you should contact the appropriate agency in the jurisdictions where you are seeking qualification, licensure or approval and obtain copies of any documentation or forms that are supplemental to this standardized form. In addition, copies of this multi jurisdictional form and all supplemental forms used by the jurisdictions accepting this form may be found on the Internet at www.iagr.org APPLICATION INSTRUCTIONS PLEASE READ ALL INSTRUCTIONS CAREFULLY BEFORE COMPLETING THIS FORM. i. COMPLETING THIS FORM: a. Initials PHDMJ061901 You must make accurate statements and include all material facts. Any misrepresentation, or the failure to provide requested information, may result in the denial of your application. Read each question carefully prior to answering. Answer every question completely. Do not leave blank spaces. If a question does not apply to you, indicate “Does Not Apply” in response to that question. If there is nothing to disclose in response to a particular question, indicate “None” in response to that question. Failure to provide a response to every question could result in the rejection of your application. All entries on this form, except initials and signatures, must be typed or printed in block lettering using dark ink. If your application is not legible, it will not be accepted. You must use blue ink to personally initial, date and identify the gaming agency to which your application is being submitted in the space provided on the bottom of each page of the form. If the space available is insufficient to respond to a question, you are to supply the required information on an attachment page and clearly identify which question you are answering. The blank page on page 65 may be used to provide this additional information. You must use blue ink to personally initial, date and identify the gaming agency to which your application is being submitted at the bottom of each of these attachment pages. If you make any modification to the pre-printed questions or information contained in this form, your application will be rejected. Once your application is accepted, it becomes the property of the gaming agency with which it has been filed and will not be returned. Gaming Agency Date Page 2 I. BE a. SURE TO: Attach a recent (within the past six months) color photograph of yourself in the space provided on page 5. Sign the Statement of Truth form on page 66 in the presence of a notary public, justice of the peace, commissioner for declarations or other person legally authorized to notarize your signature. Check to ensure that you have placed your initials, the date, and identified the gaming agency to which you are applying, on the bottom of each page of this form in the space provided and on any attachment pages. ll. BEFORE YOU SUBMIT THIS FORM TO THE GAMING AGENCY TO WHICH YOU ARE APPLYING, BE a. IV. TIP a. Initials PHDMJ061901 SURE THAT: You have reviewed the particular gaming agency’s filing instructions for the type of license, approval or qualification that you are seeking. You have included all required attachments listed in this form. The Statement of Truth form is notarized on the original application. Every question has been answered completely. You retain a completed copy of your application package for your own records. You have completed any ancillary forms for the individual jurisdictions. S FOR COMPLETING THIS FORM: Keep a blank copy of the form. When you need to update information, you can use the appropriate pages from the blank form to provide the information. Once all questions have been answered, make sufficient copies for all jurisdictions where you will file your application. Note that you should do this BEFORE the form is signed, dated and notarized. Since each jurisdiction must receive an application containing original signatures, it is advisable to make copies before signing the form. Keep an unsigned copy of your completed application. Should you need to file with another jurisdiction at some point in the future, you can then update the information rather than complete the form all over again. Be sure to use blue ink where you sign, initial, date and identify the gaming agency where you are filing your application. Using blue ink will make it clear to the jurisdiction where you are filing that your application is to be considered an original and not a photocopy. Gaming Agency. Date Page 3 MULTI JURISDICTIONAL PERSONAL HISTORY DISCLOSURE FORM PLEASE PRINT OR TYPE THE ANSWERS TO THE FOLLOWING QUESTIONS IN THE SPACES PROVIDED PERSONAL DATA NAME: LAST (INCLUDE SR., JR., ETC., IF APPLICABLE) FIRST MIDDLE MAILING ADDRESS/POSTAL ADDRESS: NUMBER AND STREET APT #/FLAT # CITY/TOWN STATE/PROVINCE ZIP/POSTAL CODE HOME ADDRESS: (IF DIFFERENT THAN MAILING ADDRESS/POSTAL ADDRESS) NUMBER AND STREET APT #/FLAT # CITY/TOWN STATE/PROVINCE ZIP/POSTAL CODE PRESENT BUSINESS ADDRESS: NUMBER AND STREET APT #/FLAT # CITY/TOWN STATE/PROVINCE ZIP/POSTAL CODE HOME TELEPHONE NUMBER: CURRENT BUSINESS TELEPHONE NO. AT PLACE OF EMPLOYMENT: FAX NUMBER: (AREA CODE) (NUMBER) (AREA CODE) (NUMBER) (AREA CODE) (NUMBER) (EXTENSION) DATE OF BIRTH: (MO)(DAY)(YEAR) E-MAIL ADDRESS (OPTIONAL): HAVE YOU BEEN KNOWN BY ANY OTHER NAME OR NAMES? YES [] NO [J IF YES, LIST THE ADDITIONAL NAMES BELOW AND SPECIFY DATES OF USE FOR EACH. (INCLUDE MAIDEN NAME, ALIASES, NICKNAMES, OTHER NAME CHANGES, LEGAL OR OTHERWISE.) SEX COLOR OF EYES COLOR OF HAIR HEIGHT FT IN/ CM WEIGHT LBS/ KG DO YOU HAVE ANY SCARS, TATOOS, OR OTHER DISTINGUISHING MARKS AND/OR CHARACTERISTICS? IF SO, PLEASE DESCRIBE. Initials PHDMJ061901 Gaming Agency Date IMPORTANT FAILURE TO ANSWER ANY QUESTION ON THIS FORM COMPLETELY AND TRUTHFULLY WILL RESULT IN DENIAL OF YOUR APPLICATION. AFFIX A COLOR PHOTOGRAPH HERE THAT WAS TAKEN WITHIN THE PAST SIX MONTHS. PRINT YOUR NAME ON THE FRONT BOTTOM BORDER OF THE PHOTOGRAPH BEFORE ATTACHING IT. Initials Gaming Agency Date Page 5 PHDMJ061901 1. Ofwhat country are you a citizen? A. Please indicate: 1. Date of birth: DAY MONTH 2. Place of birth: YEAR CITY/TOWN STATE/PROVINCE 3. Country of birth: COUNTRY 2. Have you ever been issued a passport? Yes (] No [] If yes, provide the following information about your passport(s): PASSPORT NUMBER COUNTRY OF ISSUE PLACE ISSUED DATE ISSUED EXPIRATION DATE Initials Gamin g Agency Date Page PHDMJ061901 6 3. Beginning with yo lived (including resid ur current residence(s) and working backward, provide the ences while attending college or while in military service) during the past fifteen (15) years or since the age of 18, whichever following information with respect to each place where you have is less. DATES =ROM: TO: ADDRESS OWNOR RENT | NAME, ADDRESS & TELEPHONE NO. OF LANDLORD OR (MO/YR) (MO/YR) (NO., STREET, APT#/FLAT#, CITY/TOWN, STATE/PROVINCE, COUNTRY & ZIP/POSTAL CODE) MORTGAGE/BOND HOLDER, IF KNOWN Initials Gaming A enc SREY Date PHDMJ061901 4, What is your current marital status: PAWL DIV Berl Single [] Married L_] How many times have you been married? A. CURRENT MARRIAGE Legally Separated [[] Divorced] Widow/Widower[_] Engaged C] Provide the information below regarding your current marriage and spouse: Date of Marriage: Where Married: Name of Spouse: Date of Birth: CITY/TOWN COUNTY STATE/PROVINCE COUNTRY Spouse’s Occupation: FIRST MIDOLE MAIDEN Place of Birth: DAY MONTH YEAR CITY/TOWN STATE/PROVINCE COUNTRY Telephone Number: STREET CITY/TOWN STATE/PROVINCE ZIP/POSTAL CODE AREA CODE NUMBER Home Address: B. PREVIOUS MARRIAGES Provide the information below regarding your previous marriages: (Do NOT include current spouse.) IF ANNULLED, SEPARATED ee SENT BLEREE — OR DIVORCED., INDICATE part ear # daa ADDRESSES OF FORMER SPOUSE(S) AE OEE ane ee ens se DATE AND JURISDICTION (NO., STREET, APTH/FLAT#, CITY/TOWN, eee WHERE SUCH ACTION WAS ACTION (IF STATE/PROVINCE, COUNTRY, TAKEN KNOWN) ZIP/POSTAL CODE) Initials Gaming Agency Date PHDMJ061901 5. a. Inthe chart below, list the names of all your cnildren, Step-Grinuren airy auupiou vimuren ain wis anwar ee wer cee oor persons who you are supporting or contributing to the support of, and provide the amount of support. ADDRESS AMT. OF SUPPORT NAME DATE OF BIRTH BIRTH PLACE (NO., STREET, APT., CITY, STATE, COUNTRY, ZIP CODE) (IF A DEPENDENT) 5. b. Please mark the appropriate response regarding your child support obligations: [_] |am not subject to a court order for the support of a child. {_] | am subject to a court order for the support of one or more children and am in compliance with a plan approved by the public agency/court enforcing the order for the repayment of the amount owed pursuant to the order (indicate amount in 5a. above); or [} |.am subject to a court order for the support of one or more children and am NOT in compliance with the order or a plan approved by the public agency/court enforcing the order for the repayment of the amount owed pursuant to the order. Identify the public agency/court responsible for enforcing the child support order: Name Address Contact Person Initials Gaming Agency Date ' PHDMJ061901 6. List names, residence addresses, dates of birth, and most recent OCCUPATIONS OF Parerlls, Paleis-Wiciaw, Wiig parornocu mice yur gee guardians, living or deceased. If retired or deceased, list last address and occupation: HSL oe oa DATE OF BIRTH (NO., STREET, APTHIFLAT#, sama. ST eNeR COUNTRY, ZIP/POSTAL CODE) PHONE NUMBER OCCUPATION Father: Mother: Father-in-law: Mother-in-law: Former Parents-in-law*: * For former parents-in-law only provide names. Initials Gaming Agency Date PHDMJ061901 7. List names, dates of birth, home addresses and phone numbers, and the most recent occupations of brothers and sisters and of their respective spouses: NAME ADDRESS (INCLUDE MAIDEN) DATEOF BIRTH (NO., STREET, APTHFLAT#, CITY/TOWN, STATE/PROVINCE, COUNTRY, ZIP/POSTAL CODE) PHONE NUMBER OCCUPATION Sibling: Spouse: Sibling: Spouse: Sibling: Spouse: Sibling: Spouse: Sibling: Spouse: Sibling: Spouse: Sibling: Spouse: Initials Gaming Agency. PHDMJ061901 Date EWE D beed BEN re ree me te 8. Have you ever served in a military organization of any country or have you been an active or inactive member of a reserve force of any country? Yes []No [) lf yes, provide the following information: Country of Service: Branch of Service: Service Serial #: Highest Rank Held: Period(s) of Active Service: From: To: From: To: 9. Date and type of discharge or separation (Honorable, Dishonorable, Honorable Conditions, Medical, etc.) from Military Service(s): Date of each discharge/separation: Type of discharge(s): Attach a copy of your military records” labeled as Exhibit 9M. If unavailable, attach a copy of a letter to the appropriate branch of the military requesting a copy of your military records* labeled as an Exhibit 9M. If in reserves, please attach a copy of your discharge papers. 10. Have you ever been tried by military court martial or have you had charges™ filed against you? Yes [] No (] If yes, complete the following chart: NATURE OF CHARGE DATE AND LOCATION OF NAME OF MILITARY ORGANIZATION DISPOSITION (CONVICTED, OR ARREST CHARGE OR ARREST FILING CHARGES ACQUITTED, DISMISSED, SENTENCE PLEADING, ETC.) “In the United States, a military record is called a DD214. If you have served in the U.S. milita i i ili , {is : Ss. ry, you should provide a co f th ‘ i i should provide a copy of whatever official documentation was provided to you at the time of your discharge. ‘ BaP TGONE. OUR TTY AH EE SAY GC “* Charges filed against you by the military authorities in any country would fall under the Code of Milit i i jurisdicti I ary Justice applicable to that jurisdiction. In the United States, this means any charges filed against you under Article 15 of the Uniform Code of Military Justice (summary Saul deck court, captain's mast, company punishment etc.) Initials Gaming Agency Date PHDMJ061901 ee ee 11, Beginning with secondary school (high school), provide the information listed below with respect to each school, college, graduate or post graduate school you have attended. OEP NAME AND ADDRESS OF SCHOOL, DESCRIPTION OF sp bla GRADUATED FROM: | TO: TRAINING PROGRAM, ETC. EDUCATION PROGRAM parol YES OR NO (MO/YR) | (MO/YR) Initials Gaming Aqen g Agency, Date PHDMJ061901 12. List all offices, trusteeships, directorships or fiduciary positions (including non-profit charitable entities and family trusts) held by you with any firm, corporation, association, partnership or other business entity during the last ten year period. Begin with the most recent and work backward. DATES FROM: TO: TITLE OF OFFICE OR POSITION HELD NAME AND ADDRESS OF FIRM, CORPORATION, COMPENSATION (MO”vR) | (MOIR) ASSOCIATION, PARTNERSHIP OR OTHER BUSINESS ENTITY RECEIVED . Initials Gaming Agency Date PHDMJ061901 DATES NAME AND ADDRESS OF FIRM, CORPORATION, COMPENSATION ASSOCIATION, PARTNERSHIP OR OTHER BUSINESS ENTITY RECEIVED ROW To: TITLE OF OFFICE OR POSITION HELD (Mo/yR) | (MO/YR) 13. List all government positions and offices, whether salaried or unsalaried, held by you during the last ten year period. Begin with the most recent and work backward. DATES FROM: TO! (MO/YR) (MO/YR) TITLE OF OFFICE OR POSITION HELD NAME AND ADDRESS OF GOVERNMENT AGENCY/ORGANIZATION ° Initials Gaming Agency Date PHDMJ061901 14. Have you ever been employed by a casino or gaming/gambling related company in any jurisdiction? *Casino or gaming/gambling related company includes any form or type of casino, gaming/g gaming/gambling equipment, junket enterprise, horse racing, dog racing, pari-mutuel operation, lottery, Yes [] No ambling related operation, any manufacturer of sports betting, Internet gaming, etc. NAME OF GAMING/GAMBLING NAME, MAILING DATES EIPOSITION WELD AND GAMING RELATED COMPANY ADDRESS AND AND COUNTRY/STATE WHERE | TELEPHONE NUMER OF FROM TO DESCRIPTION OF DUTIES NAME OF SUPERVISOR REASON FOR LEAVING YOU WERE EMPLOYED EMPLOYER(S) (MO/YR) (MO/YR) Date PHDMJ061901 45. In the chart below, provide the information regarding your employmen your present job and work backwards. Give dates of any unemploym employment and any military service. For any casino or gaming/gamblin required to fill in the dates of employment and the name of the ca t for the past twenty years or from age 18, whichever is less. Begin with ent between jobs in proper sequence. Include all part-time and full-time g related employment identified in the previous question, you are only sino or gaming/gambling related company on this chart. DATES FROM: TO: (MO/YR) | (MO/YR) NAME, MAILING ADDRESS, AND TELEPHONE NUMBER OF EMPLOYER(S) TITLE/POSITION HELD AND DESCRIPTION OF DUTIES NAME OF SUPERVISOR REASON FOR LEAVING/ COMPENSATION AT DEPARTURE Initials PHDMJ061901 Gaming Agency Date 15, (CONT) DATES FROM: (MO/YR) TO: (MO/YR) NAME, MAILING ADDRESS, AND TELEPHONE NUMBER OF EMPLOYER(S) TITLE/POSITION HELD AND DESCRIPTION OF DUTIES NAME OF SUPERVISOR REASON FOR LEAVING/ COMPENSATION AT DEPARTURE Initials PHDMJ061901 If additional space is needed, please provide an attachment. Gaming Agency. Date a. Were you ever discharged, suspended or aske b. During the last ten year period, were you ever ch in relation to any employment which was the subje lf yes to either question, complete the following cha d to resign from employment? arged with any infraction ct of any disciplinary action? Yes (] Yes [_] rt as to each such time you were discharged, suspended, asked to resign or disciplined: No (] No [] DATE OF DISCHARGE ; NAME OF REASON FOR DISCHARGE, SUSPENSION SUSPENSION, RESIGNATION NAME AND ADDRESS OF EMPLOYER 4 eatel ay tear Bene SUPERVISOR RESIGNATION OR DISCIPLINARY ACTION Initials Gaming Agency Date PHDMJ061901 17. List any and all Compensateu einpiuyiicii, Ur wiiawever seemery cm my a spouse's current employer. DATES NAME, ADDRESS AND TELEPHONE NUMBER OF EMPLOYER TITLE/ FROM: TO: POSITION HELD (MO/YR) | (MO/YR) 18. To the best of your Knowledge, have you or has your spouse served as a trustee or other fiduciary officer in any capacity during the last twelve month period? . Yes [] No [] lf yes, complete the following chart: DATES FROM: To: CAPACITY NATURE OF TRUST INCOME RECEIVED FOR WHOM HELD (MO/YR) | (MO/YR) OR OTHER FUND Initials Gaming Agency Date Page 20 PHDMJ061901 19. a, Have you or your spouse ever sougnt and Deen demied 4 pusiiurs ao a wucwee wi yas wmemwnary weer: b. Have you or your spouse ever been suspended or removed from a If yes to either question, complete the following chart: position as a trustee or other fiduciary officer? Yes LC] No LJ DATE CAPACITY NATURE OF TRUST OR OTHER OFFICE REASON FOR DENIAL, SUSPENSION OR REMOVAL 20. Have you or has your spouse ever made application for, or held, any NON-GAMING professional or occupational license, permit or certification in any jurisdiction, including but not limited to the following: real estate broker or salesman, accountant, attorney, medical, boxing promoter, manager or matchmaker, race horse owner, trainer or manager, jockey, race dog owner, securities dealer, contractor pilot, insurance, or any other type of professional license. (Do not include alcoholic beverage or driver's license). You must answer “YES” to this question if you ever applied and your application was granted, denied, returned to you by the licensing agency for any reason, withdrawn or is currently pending. ¥ If yes, complete the following chart: in ie DATES NAM E ON LICENSE TYPE OF LICENSE FROM: TO: NAME AND ADDRESS DISPOSITION OF (MO/YR) (MO/YR) OF LICENSING AGENCY/ORGANIZATION THE APPLICATION Initials Gaming Agency Date PHDMJ061901 ee 21. Have any of the licenses, permits or certifications applied for, ur rei vy yuu wr yur opemowy ae were « denied, suspended, revoked or subject to any conditions in any jurisdiction? Yes [] No [J If yes, complete the following chart as to each denial, suspension, revocation or conditions: DATE OF DENIAL, TYPE OF LICENSE, NAME & ADDRESS OF SUSPENSION. REVOCATION REASON(S) FOR DENIAL PERMIT OR CERTIFICATE GOVERNMENTAL AGENCY/ORGANIZATION OR CONDITION SUSPENSION OR REVOCATION 22. Has any entity in which you, or your spouse, is/was a director, officer, partner or an owner of a 5% or greater interest ever had any license permit or certificate issued by a governmental agency in any jurisdiction denied, suspended, revoked, or subject to any conditions? . Yes No lf yes, complete the following chart as to each denial, suspension or revocation: = TYPE OF NAME AND ADDRESS OF NAME OF ENTITY | COSITION HELD BY LICENSE, TYPE OF GOVERNMENT DATE OF REASONS) OU OR YOUR SPOUSE PERMIT OR ACTION TAKEN AGENCY/ORGANIZATION TAKING ACTION FOR CERTIFICATE ACTION ACTION Initials Gaming Agency Dat € PHDMJ061901 esses in which you have held an ownership interest of 5% or more for the past 23, List any group, firm, partnership, corporation or any other busin include publicly traded corporations in which you owned stock.) twenty years, or since the age of 18, whichever is less. (Do not DATES FROM: To: NAME(S) & ADDRESS(ES) CURRENT STATUS | % INTEREST NAME(S) OF ADDRESS(ES) STATE/PROVINCE (MOrYR) | (MO/YR) OF BUSINESS(ES) OF BUSINESS(ES) HELD BY OTHER OWNERS OF OTHER OWNERS AND COUNTRY OF YOU ORGANIZATION OR INCORPORATION Initials Gaming Agency Date PHDMJ061901 our spouse ever made application for, or held, a license, permit, registration, finding of suitability, qualification or other in any form or type of casino, gaming/gambling related operation (including any manufacturer of gaming/gambling equipment, junket operation, horse racing, dog racing, pari-mutuel operation, lottery, sports betting, Internet gaming, etc.) or alcoholic beverage operation in any jurisdiction? You must answer “YES” to this question if you ever applied and your application was granted, denied, returned to you by the gaming agency for any reason, withdrawn or is currently pending. Yes [] No [J 24. Have you or has y authorization to participate If yes, complete the following chart: LICENSE, PERMIT, NAME & ADDRESS OF LICENSING AGENCY/ORGANIZATION TYPE OF LICENSE, DATE OF DISPOSITION APPROVAL OR (INCLUDING COUNTRY, STATE/PROVINCE, COUNTY PERMIT, APPROVAL APPLICATION (GRANTED, DENIED REGISTRATION OR MUNICIPALITY/TOWN) OR REGISTRATION OR PENDING, ETC.) NUMBER Initials Gaming Agency Date PHDMJ061901 25. For each casino, gaming/gambling related or alcoholic beverage operation application, license, permit, registration, finding of suitability, qualification or other authorization identified in the previous question, were you or your spouse ever called to appear to testify, or otherwise participate in a hearing or proceeding, before the licensing agency or commission to which you were applying? Yes [] No (J lf yes, complete the following chart: NAME AND ADDRESS OF LICENSING AGENCY OR COMMISSION DATE OF APPEARANCE(S) NATURE OF HEARING WAS TESTIMONY GIVEN? Initials Gaming Agency Date PHDMJ061901 past twenty years or since the age of 18, whichever is less, have you held a direct or indirect financial or tion, partnership or other business entity that has applied to any licensing agency in any jurisdiction or qualification in connection with any form or type of a casino, gaming/gambling related quipment, junket operation, horse racing, dog racing, pari-mutuel operation, lottery, Do not include publicly traded corporations or entities in which you held 26. To the best of your knowledge, in the ownership interest in any group, firm, corpora for any license, permit, registration, finding of suitability, operation (including any manufacturer of gaming/gambling e sports betting, Internet gaming, etc.), or alcoholic beverage operation? ( less than 1% of the stock.) Yes [] No (J lf yes, complete the following chart: NAME & ADDRESS OF LICENSING NAME AND ADDRESS NATURE OF DATE OF AGENCY TYPE OF LICENSE DISPOSITION OF OF BUSINESS ENTITY YOUR INTEREST APPLICATION TO WHICH APPLICATION WAS MADE APPLIED FOR APPLICATION Initials Gaming Agency. Date PHDMJ061901 spouse, parents, grandparents, children, grandchildren, siblings, uncles, aunts, nephews, nieces, fathers-in- law, brothers-in-law and sisters-in-law whether by whole or half blood, by marriage, adoption form or type of casino or gaming/gambling related operation as defined in 27. a. Are any members of your family ( law, mothers-in-law, sons-in-law, daughters-in- or natural relationship) associated with or employed in any question 26 in any jurisdiction? Yes [] No (J b. Do you or any members of your family (spouse, parents, grandparents, children, grandchildren, siblings, uncles, aunts, nephews, nieces, fathers-in-law, mothers-in-law, sons-in-law, daughters-in-law, brothers-in-law and sisters-in-law whether by whole or half blood, by marriage, adoption or natural relationship) have an ownership interest in any alcoholic beverage entity in any jurisdiction? Yes [] No L] If yes to either question, complete the following chart: NAME OF PERSON RELATIONSHIP NAME OF GAMING/GAMBLING OR ALCOHOLIC BEVERAGE BUSINESS BUSINESS TELEPHONE AND ADDRESS Initials Gaming Ai is ee iey, Date PHDMJ061901 CIVIL, CRIMINAL AND INVESTIGATORY PROCEEDINGS The next question asks about any arrests, charges or offenses you, your spouse or your children may have committed. Prior to answering this question, carefully review the definitions and instructions which follow. DEFINITIONS: For purposes of this question: A. “Arrest” includes any detaining, holding, or taking into custody by any police or other law enforcement authorities to answer for the alleged performance of any “offense.” B. “Charge” includes any indictment, complaint, information, summons, or other notice of the alleged commission of any “offense.” C. “Offense” includes all felonies, crimes, high misdemeanors, misdemeanors, disorderly persons offenses, petty disorderly offenses, driving while intoxicated/impaired motor vehicle offenses and violations of probation or any other court order. Juvenile offenses that occurred within the most recent 10 year period are also included within the definition of “offenses.” INSTRUCTIONS: 1. Answer “YES” and provide all information to the best of your ability EVEN IF: A. You did not commit the offense charged; The charges were dismissed or subsequently downgraded to a lesser charge; You completed a Pretrial Intervention (PTI) or equivalent diversionary program in other jurisdictions; You were not convicted; J a You did not serve any time in prison or jail; or F. The charges or offenses happened a long time ago. 2. Answer "NO" IF any records relating to a charge, an arrest or conviction have been expunged or otherwise officially sealed by a court or government agency . Some jurisdictions permit the gaming agency to obtain information about the expungement or sealing order as part of the licensing process. You should confer with the gaming agency to which you are applying to determine the applicable law. IMPORTANT The gaming agency will make inquiries to establish whether the applicant has had any involvement with law enforcement agencies. Failure to disclose any such involvement will be taken into account in assessing your character, honesty and integrity. Initials Gaming Agency Date PHDMJ061901 - 28. Have you ever been arrested or charged with any crime or offense in any jurisdiction? Yes [] No CJ lf yes, complete the following chart: DISPOSITION NATURE OF CHARGE OR OFFENSE/ DATE OF CHARGE OR — AU EREORGERERT GENS (CONVICTED, ACQUITTED, ape URe LOCATION OF WHERE INCIDENT OCCURRED OFFENSE See Finouve DISMISSED, PENDING, PARDONED, ETC.) Initials Gaming Agency _ PHDMJ061901 t, information or complaint ever been filed or returned against you, but for which you dicted party or unindicted co-conspirator in any criminal proceeding in any jurisdiction? Yes [] No [J 29. To the best of your knowledge, has a criminal indictmen were not arrested or in which you were named as an unin If yes, complete the following chart: NAME AND ADDRESS OF NATURE OF PROCEEDING DATE GOVERNMENTAL AGENCY/ORGANIZATION INVOLVED 30. Have you ever been the subject of an investigation conducted by any governmental agency/organization, court, commission, committee, grand jury or investigatory body (local, state, county, provincial, federal, national, etc.) other than in response to a traffic summons? If yes, complete the following chart: Yen) Bed NAME AND ADDRESS OF NATURE OF PROCEEDING WAS T ESTIMONY DAT COURT OR OTHER AGENCY OR INVESTIGATION GIVEN? TESTIMONY TIME PERIOD OF WAS GIVEN INVESTIGATION Initials Gaming Agency Date PHDMJ061901 i i ted to take a polygraph exam by any ever been called to testify before, or otherwise been questioned, interviewed, deposed, or reques oly oh a povernmental agency/organization, court, commission, committee, grand jury or investigative body (local, state, county, provincial, federal, national, etc.) in any jurisdiction other than in response to a traffic summons: Yes H No b. Have you ever been subpoenaed to appear or testify before a federal, national, state, county grand jury, or other criminal investigatory agency or or commission, or any civil, criminal or administrative proceeding or hearing: body, or any board y Yes) No O lf yes to either question, complete the following chart: H APPROXIMATE NAME AND ADDRESS OF NATURE OF PROCEEDING WAS TESTIMONY | DATE ON WHIC OR INVESTIGATION GIVEN? TESTIMONY TIME PERIOD OF COURT OR OTHER AGENCY/ORGANIZATION TESTIMONY ME PERIOD OF 32. Have you ever received a pardon, or has any government agency/organization agreed to dismiss, suspend or defer any criminal investigation or prosecution against you for any criminal offense? . Yes [] No [] If yes, complete the following chart: DATE OF PARDON, DIGMISEAL, SUSPENSION: TVPSHORATIONCTARER NAME AND ADDRSS OF GOVERNMENT AGENCY/ORGANIZATION GRANTING PARDON, DISMISSAL SUSPENSION OR DEFERAL OR DEFERAL Initials Gaming Agenc PHDMJ061901 33. Has your spouse or any of your children, s tep-children or adopted children ever been arrested or charged with any crime or offense (as defined at the beginning of this section) in any jurisdiction? . Yes [] No [J lf yes, complete the following chart: DISPOSITION NATURE OF DATE OF NAME & ADDRESS OF LAW NAME OF PERSON RELATIONSHIP CHARGE OR CHARGE OR | ENFORCEMENT AGENCY Secu dlted ponte SENTENCE OFFENSE FFEN ’ N OFFENSE OR COURT INVOLVED PARDONED, ETC.) Initials Gaming Agency. Dat ale PHDMJ061901 34. In the past fifteen (15) years, have you as an individual, member of a partnership, or owner, director, or officer of a corporation, ever been a party to a lawsuit, as either a plaintiff or defendant or an arbitration as either a claimant or defendant? (Include matrimonial matters, negligence matters, auto accident matters, contract matters, collection matters, debt matters, bankruptcies, etc.) Yes [.] No (] If yes, complete the following chart: DATE NAME & ADDRESS DOCKETICASE | OTHER PARTIES TO SUIT NATURE OF SUIT DISPOSITION DATE OF FILED OF COURT NUMBER DISPOSITION Initials Gaming Agen eneeepeerepyemnsamnine Cc SIMBENCY, Date PHDMJ061901 35. In the past fifteen (15) years, has any general partnership, associated with as an owner, Officer, director or partner, business venture, sole proprietorship or closely held corporation, which you were been a party to a lawsuit, arbitration or bankruptcy? Yes [] No [] lf yes, complete the following chart: WHERE ACTION FILED APPROXIMATE DATE(S) OF ERE OF ENE’ TYPE OPENED LAWSUIT/ARBITRATION/BANKRUPTCY (chs ew Initials Gaming Agency — PHDMJ061901 violation of a statute, regulation or code of any local, s, have you been cited or charged with, or formally accused of, any disorderly persons, petty disorderly person or motor 36. In the past ten year: provincial, federal or national government other than a criminal, state, county, municipal, vehicle violation? Yes [] No (J lf yes, complete the following chart: GOVERNMENTAL AGENCY/ORGANIZATION NATURE OF CHARGE DATE DISPOSITION Initials Gaming Agency Date PHDMJ061901 37. Have you ever been barred or otherwise excluded, for a registration, from any form or type of casino or exclusion is no longer in effect or has been lifted.) lf yes, complete the following chart: ny reaso gaming/gambling related operation in any jurisdiction? ( n, other than for the denial, suspension or revocation of a license or Check “YES” even if the disbarment or Yes [1] No (] . GAMING/GAMBLING AGENCY DATE OF EXCLUSION REASON FOR EXCLUSION VEHICLE OPERATOR DATA . . . 4i ti ’ | ’ | la Ss, boat ’ j DATE LAST ISSUED LICENSE NUMBER TYPE OF LICENSE JURISDICTION ISSUING LICENSE me al Initials Gaming Agency. Date PHDMJ061901 39. Have any individual, local, city, county, provincial, state, Federal, national, or owner of a corporation in any jurisdiction? FINANCIAL DATA or any other governmental liens/debts been filed against you as an individual, sole proprietor, member of a partnership, Yes [] No (J lf yes, complete the following chart: NATURE OF LIEN/DEBT WHEN FILED WHERE FILED CURRENT STATUS Initials Gaming A acl Date PHDMJ061901 40. Have you personally ever been adjudicated bankrupt or filed a petition for any type of bankruptcy, insolvency or liquidation under any bankruptcy or insolvency law in any jurisdiction? : Yes [] No (J lf yes, complete the following chart: DATE FILED DOCKET/CASE NUMBER NAME AND ADDRESS OF COURT NAME AND ADDRESS OF TRUSTEE 41. In the past twenty years or since the age of 18, whichever is less, has any business entity in which you held a 5% or greater ownership interest, or in which you served as an officer or director been adjudicated bankrupt or filed a petition for any type of bankruptcy or insolvency under any bankruptcy or insolvency law? Yes [] No [] If yes, complete the following chart: ae Oe NAME AND ADDRESS OF COURT NAME AND ADDRESS OF FILING PARTY NAME AND ADDRESS OF TRUSTEE Initials Gaming Agency Date P age 38 PHDMJ061901 42. Have you as an indi vidual, member of a partnership, or owner, director or officer of a corporation ever been in a business entity that has been in laced under some form of governmental administration or monitoring? liquidation, receivership or been p Yes [] No (] If yes, complete the following chart: DATE PLACED NAME AND ADDRESS OF BUSINESS UNDER YOUR RELATIONSHIP TO REASON PLACED UNDER LIQUIDATION ENTITY LIQUIDATION, : PRESENT STATUS BUSINESS ENTITY RECEIVERSHIP, RECEIVERSHIP, ETC. ETC. . ’ ’ ’ ’ If yes, complete the following chart: Yes No DAT DATE DOCKETICASE NAME AND ADDRESS OF COURT NATURE OF AMOUNT OF NAME AND ADDRESS OF OBLIGATION OBLIGATION HOLDER OF OBLIGATION Initials Gaming Agency Dat e PHDMJ061901 44. In the past ten years, have you ever had any prop erty, real or personal, repossessed by a finance company in any jurisdiction? Yes [] No (J lf yes, complete the following chart: NAME AND ADDRESS OF COMPANY TYPE OF PROPERTY DATE REPOSSESSED REPOSSESSING PROPERTY REASON FOR REPOSSESSION 45. During the last ten year period, have you been: a. An executor(trix), administrator or other fiduciary of any estate; b. A beneficiary or legatee under a will or received any thing of value under an intestacy statute; or c. Asettlor/grantor, beneficiary or trustee of any trust? Yes [] No (] lf yes, complete the following chart as to each estate and trust: NAME AND LOCATION POSITION/ INTEREST HELD DATE(S) ON WHICH AMOUNT OF COMPENSATION OR OF ESTATE/TRUST POSITIONS NATURE AND VALUE OF WERE HELD OR INTEREST BENEFIT GRANTED/RECEIVED WAS RECEIVED Initials j Gaming Agency Date PHDMVJ061901 46. Do you own, hold, or have an interest in any assets in a trust in any j question 45). lf yes, complete the following chart: urisdiction? (You may exclude those assets disclosed in your answer to Yes [] No (J DESCRIPTION OF TRUST LOCATION OF TRUST NAME OF TRUSTEE(S) NAMES OF OTHER(S) WITH INTERESTS IN TRUST 47, Do you hold, manage or control in trust, or otherwise, any assets or liabilities for another perso ity i jurisdicti , Manage ' ' n or entity in any juri fa those assets or liabilities disclosed in your answer to question 45). P / SARA FOMEIES EKER lf yes, complete the following chart: Yes J No DESCRIPTION OF ON OF TRUST LOCATION OF TRUST NAMES OF OTHER(S) WITH INTEREST IN TRUST Initials Gaming Agency Dat ate PHDMJ061901 48. a. Please state your country of residence b. During the last ten year period have you had any right of ownership in, control over or interest in any bank account(s), which are located outside the country of residence identified in a. above? . Yes [] No [J If yes, complete the following chart: DATES NAME AND ADDRESS OF ACCOUNT NUMBER NAME AND ADDRESS OF PRESENT AMOUNT HELD/ FROM: TO: INSTITUTION HOLDING ACCOUNT EACH PERSON/ENTITY APPEARING AMOUNT HELD BEFORE (MO/YR) | (MO/YR) ON THE ACCOUNT CLOSING Initials Gaming Agency. Date PHDMJ061901 - c. Do you own, manage or control any assets, or are you responsible for any liabilities, located outside the country of residence as identified in a. above (excluding any foreign bank accounts identified in b. above)? If yes, complete the following chart: Yes [] No [] DESCRIPTION OF ASSET/LIABIITY LOCATION OF ASSETI/LIABILITY 49. During the last ten year period, have you or has your s (If you are applying in a jurisdiction other than the United States, the a filing this application.) pouse or any of your children, while dependent, received a loan in excess of $25,000USD? mount you are required to report is the equivalent to $25,000USD in the national currency of the jurisdiction where you will be Yes [] No [] If yes, complete the following chart: DATE NAME AND ADDRESS NAME OF BORROWER ORIGINAL INTEREST | TERMINATION RECEIVED OF LENDER AND ALL CO-SIGNERS AMOUNT RATE DATE LOAN OF LOAN (%) OF LOAN Initials Gaming Agenc PHDMJ061901 made any loan in excess of $10,000USD? r period, have you or has your spouse or any of your children, while dependent, m 3s of $1 : oe oe 9 the a * eden other than Ay United Mae amount you are required to report is the equivalent of $10,000USD in the national currency of the jurisdiction where you will be filing this application.) = 0 Ns 7 lf yes, complete the following chart: DATE NAME AND ADDRESS ALL CO-PARTIES NAME OF LENDER ORIGINAL INTEREST | TERMINATION SECURITY OF LOAN OF BORROWER TO LOAN AMOUNT RATE DATE PLEDGED OF LOAN (%) OF LOAN 51. Have you individually ever exchanged currency in an amount of more than $10,000USD within the past ten years? (if you are applying in a jurisdiction other than the United States, the amount you are required to report is the equivalent of $10,000USD in the national currency of the jurisdiction where you will be filing this application.) Yes [.] No [] lf yes, complete the following chart: DID YOU FILL OUT OR FILE ANY ATE AND AMOUNT OF EXCHAN H MADE DATE AND AMOUNT O Cc GE LOCATION WHERE EXCHANGE MAD REASON FOR EXCHANGE GOVERNMENTAL REPORTING DOCUMENT - Initials Gaming Agency Date PHDMJ061901 intai i t with any securities or commodities dealer? 52. Do you maintain a brokerage or margin accoun y ves ) No O lf yes, complete the following chart: TYPE OF ACCOUNT NAME AND ADDRESS OF DEALER AMOUNT OF MARGIN 53, Have you or has your spouse or children, while dependent, filed any claims in excess of $100,000USD under any fire, theft, automobile or insurance policy within the past ten year period? (if you are applying in a jurisdiction other than the United States, the amount you are required to report is the equivalent of $100,000USD in the national currency of the jurisdiction where you will be filing this application.) Yes [] No [] If yes, complete the following chart: DATE NATURE OF CLAIM NAME AND ADDRESS OF DISPOSITION OF CLAIM INSURANCE CARRIER Initials Gaming Agenc y Date Page 45 PHDMJ061901 ur spouse or dependent children given or received any gift or gifts, whether tangible or intangiole ded $10,000USD in value in any one year period? (if you are applying in a jurisdiction other than the United States, tional currency of the jurisdiction where you will be filing this application.) 54. During the last five year period, have you, yo which either individually or in the aggregate excee the amount you are required to report is the equivalent of $10,000USD in the na 9 7 Yes No If yes, complete the following chart as to each gift: NAME OF THE DATE GIFT DESCRIPTION OF GIFT APPROXIMATE DONOR OR DONEE GIVEN/RECEIVED VALUE 55. a. Do you have any safe deposit boxes in your name in any jurisdiction? Yes [] No (] b. Do you have access to the funds in any other safe deposit boxes in any jurisdiction? Yes [] No (] If yes to either question, complete the following chart: NAME AND ADDRESS OF BANK OR OTHER NAME(S) IN WHICH ACCOUNT(S) TYPE OF ACC INSTITUTION/BUSINESS WHERE LOCATED OR SAFE DEPOSIT BOX(ES) HELD (SAVINGS, CHECKING, SAFE DEPOSIT BOX NO SAFE DEPOSIT, ETC.) : Initials Gaming Agency. Dat e PHDMJ061901 SCHEDULE “C” - SECURITIES 62. Provide the information in the table below for all stocks, bonds, mutual funds, commodity accounts, options, warrants, etc., held or controlled by you, your spouse or dependent children in any jurisdiction. Whenever interest exists through a mutual fund or holding company, the individual stocks or bonds held by such mutual fund or holding company need not be listed; whenever such interest exists through a beneficial interest in a trust, the securities held in such trust shall be listed if you, your spouse or dependent children have knowledge of what securities are so held. INDICATE PUBLICLY TRADED SECURITIES BY AN ASTERISK(* ). CHECK IF HELD BY NUMBER OF NAME OF -.z oo SPOUSE SECURITIES | TYPE OF ISSUING H<se DATE OF =H REGISTERED DATE CURRENT nee ee OR SECURITY | COMPANY OR GOVERNMENT wind AND PRICE ons z OWNER OF MARKET EPENDENT | CONTRACTS AGENCY/ORGANIZATION oe AT PURCHASE sea VALUATION VALUE CHILD HELD =F 8 z z= $ ————EE————————— $ TOTAL sUeciaae TOTAL CURRENT ae MARKET VALUE (Enter this figure in (Enter this figure in item 3, column A item 3, column B on page 48.) on page 48.) Initials, Gaming Agency Date PHDMJ061901 SCHEDULE “D” - REAL ESTATE INTERESTS 63. Indicate below the location, size, general nature, acquisition date and other information requested regarding any real property in any jurisdiction in which any direct, indirect, vested or contingent interest is held by you, your spouse or dependent children, along with the names of all individuals or entities who share a direct, indirect, vested or contingent interest therein. CHECK INDIVIDUALS OR IF HELD BY ADDRESS LOT SIZE/ DATE ENTITIES SHARING PURCHASE MONTHLY ESTIMATED SPOUSE PARCEULOT STAND NO./ TYPE OF ACQUIRED/ INTEREST PRICE OF RENTAL MARKET VALUE OR NUMBER SQUARE PROPERTY DOWN INCLUDE % OF % OWNED INCOME, OF % OWNED DEPENDENT FOOTAGE PAYMENT OWNERSHIP FOR EACH Pant CHILD OF BUILDING $. $ TOTAL PURCHASE TOTAL CURRENT PRICE MARKET VALUE (Enter this figure in (Enter this figure in item 4, column A item 4, column B on page 48.) on page 48.) Initials Gaming Agency Date PHDMJ061901 64, Indicate below the informat SCHEDULE “E” - CASH VALUE - LIFE INSURANCE ion requested with regard to the cash value of all life insurance policies held by you, your spouse or your dependent children. CHECK IF HELD BY ANNUAL CASH EFFECTIVE SPOUSE DATE INSURANCE CARRIER BENEFICIARY (IES) FACE PREMIUM SURRENDER DATE OR PURCHASED POLICY NUMBER VALUE PAYMENTS VALUE OF CASH DEPENDENT SURRENDER CHILD VALUE TOTAL CASH SURRENDER VALUE (Enter this figure in item 5, column B on page 48.) Initials Gaming Agency Date PHDMJ061901 SCHEDULE “F” - CASH VALUE - PENSION/RETIREMENT FUNDS 65. Indicate below the information requ ested with regard to the cash value of all retirement/investment/pension funds* held by you or your spouse. FECTIVE CHECK CUMULATIVE CUMULATIVE CURRENT ae i TYPE OF EMPLOYER CASH r pis SECURITIES EMPLOYER/ EMPLOYEE P CONTRIBUTION VALUE CASH LO CONTRIBUTIO be FUND HELD AND INSTITUTION VALUE E ACCOUNT olen NUMBER, IF ANY $ $ TOTAL TOTAL CUMULATIVE CURRENT CASH EMPLOYEE VALUE CONTRIBUTION (Enter this figure in (Enter this figure in item 6, column B item 6, column A on page 48.) on page 48.) *If you are filing this application in the United States, the information is to include IRA, 401K and KEOGH plans. Initials Gaming Agency Date Page 54 PHDMJ061901 SCHEDULE “G” - VEHICLES 66. Indicate below the information requested with regard to all vehicles owned or leased by you, your spouse, or your dependent children. CHECK IF HELD SPECIFY IF DATE OF SHEL eacereascet IF OWNED, Y Pada CURRENT BY SPOUSE OR OWNED OR PURCHASE? OF VEHCILE cos ysrOue TYPE OF VEHICLE WED © RCHAS GAG ENT Mi CHILD $ $ TOTAL TOTAL “If leased, specify in this column the length of the lease, total lease costs, down payments, monthly payments VEHICLES saat ha and number of payments over the life of the lease. “If leased, enter the sum of the down payment plus monthly payments to date as the total cost. Initials PHDMJ061901 Gaming Agency Date (Enter this figure in Item 8,column A on page 48.) (Enter this figure in Item 8,Column B on page 48.) SCHEDULE “H” - OTHER ASSETS er assets, including any business investments in which any direct, indirect, vested or 67. List below the information requested regarding all oth contingent is held by you, your spouse or your dependent children. Business interests should include, but not be limited to, joint ventures, s. Other assets should include, but not be limited to, art collections, coin collections, and partnerships, sole proprietorships, corporations and LLC antiques. CHECK IF HELD BY NATURE % OF DATE CURRENT SPOUSE OF DATE OF COST OWNERSHIP OF MARKET OR ASSET ACQUISITION INTEREST VALUATION VALUE DEPENDENT CHILD $ $ lord TOTAL CURRENT OF MARKET VALUE OF OTHER ASSETS OTHER ASSETS (Enter this figure in ; ; item 9, column A yr datas ca on 48. tem 9, column page 48.) on page 48.) ~ Initials Gaming Agency Date - PHDMJ061901 SCHEDULE “I” - NOTES PAYABLE 68. List below the information requested with regard to all notes payable for which you, your spouse or dependent children are obligated. AMOUNT —_ OF ORIGINAL NATURE OF aor > %& | NAME &ADDRESS | ACCOUNT 9 HS PERIODIC AMOUNT a A Ee LIABILITY =aO%q| OFCREDITOR NUMBER, ws oe w W at PAYMENTI OF NOTE IF ANY PAYMENTS SARea IF ANY <5 ag ul Fe PAY FSOR 2 zo PERIOD saa pra) $ TOTAL ORIGINAL TOTAL AMOUNT AMOUNT OF OF OUTSTANDING NOTES PAYABLE NOTES PAYABLE (Enter this figure in (Enter this figure in item 10, column C item 10, column D on page 48.) on page 48.) Initials Gaming Agency. Date Page 57 PHDMJ061901 SCHEDULE “J” - LOANS AND OTHER PAYABLES 69. List below the information requested with regard to all accounts payable (include lines of credit, installment loans, revolving charge accounts and any other accounts) for which you, your spouse or your dependent children are obligated. CHECK IF NAME & ADDRESS ACCOUNT a 8 ae NATURE ORIGINAL NATURE OF 2 CURRENT a OF CREDITOR ee ¥ w c = w w= aes AMOUNT OF SECURITY, z a AMOUNT w LIA DEPENDENT rs 3 ag z S BILITY IF ANY i) = OUTSTANDING CHILD < = é . $ TOTAL ORIGINAL TOTAL AMOUNT AMOUNT OF OF OUTSTANDING LIABILITY LOANS AND (Enter this figure in P pes item 11, column C AYABLES F on page 48.) a this figure in ’ item 11, column D on page 48.) Initials Gami ng Agenc ene, Date PHDMJ061901 . SCHEDULE “K” - TAXES PAYABLE i igated. 70. List below the information requested with regard to all taxes payable for which you, your spouse, or your dependent children are obligate Only real estate and income taxes need to be included. CHECK IF TOTAL Y DATE AND FINES, Grouse gi OF TAX AMOUNT OF PENALTIES AMOUNT OR AUTHORITY ORIGINAL AND INTEREST, DUE DEPENDENT OBLIGATION IF ANY CHILD TOTAL ORIGINAL TOTAL AMOUNT TAX OF TAXES OBLIGATION(S) PAYABLE (Enter this figure in (Enter this figure in item 12, column C item 12, column D on page 48.) on page 48.) Initials Gaming Agency Date Page 59 PHDMJ061901 SCHEDULE “L” - MORTGAGES OR LIENS PAYABLE ON REAL EvIAIE 71. List below the information requested with regard to all mortgages or liens due and owing on real estate for which you, your spouse or your dependent children are obligated. CHECK IF OWED BY NAME AND ADDRESS c ORIGINAL DESCRIPTION/ ue a ieee OOF 5 CURRENT SPOUSE OF MORTGAGEE ACCOUNT Ww oe AMOUNT OF ADDRESS OF Ozeye bode MORTGAGE OR OR LIEN HOLDER NUMBER <& LIABILITY REAL ESTATE . Cow sOsw BALANCE DEPENDENT ao ux Ss Ouz> CHILD < =< goa $ $ TOTAL ORIGINAL MORTGAGES OR TOTAL LIENS PAYABLE MORTGAGES OR ON REAL ESTATE LIENS PAYABLE (Enter this figure in ON REAL ESTATE item 13, column C (Enter this figure in on page 48.) item 13, column D on page 48.) Initials Gaming Agency. Date PHDMJ061901 SCHEDULE “M” - LOANS AGAINST INSURANCE/PENSION PLANS 72. List below the information requested with regard to all loans against life insurance policies, pension plans, etc., taken by you, your spouse or your dependent children. CHECK IF OWED BY PERIODIC SPOUSE INSURANCE CARRIER/ PURPOSE ORIGINAL INTEREST DATE PAYMENT CURRENT OR PENSION PLAN OF LOAN AMOUNT OF RATE OF AMOUNT/ LOAN DEPENDENT LOAN (%) LOAN PAY BALANCE CHILD PERIOD ; $ TOTAL ORIGINAL TOTAL AMOUNT LIABILITY PENSION LOANS INSURANCE/PENSION (Enter this figure in LOANS _ item 14, column C (Enter this figure in on page 48.) item 14, column D on page 48.) > Initials Gaming Agency Date - PHDMJ061901 SCHEDULE “N” - ANY OTHER INDEBTEDNESS 73. List below the information requested with regard to any other indebtedness for which you, your spouse or your dependent children are obligated. CHECK IF DESCRIPTION OF OWED BY LIABILITY, TYPE OF AMOUNT OF ORIGINAL OUTSTANDING SPOUSE NAME AND ADDRESS INTEREST OBLIGATION AND DUE PERIODIC AMOUNT OF AMOUNT OF OR OF CREDITOR RATE NATURE OF DATE PAYMENT/ LIABILITY INDEBTEDNESS DEPENDENT (%) SECURITY, PAY PERIOD CHILD IF ANY $ $ TOTAL TOTAL AMOUNT ORIGINAL OUTSTANDING AMOUNT OTHER OTHER INDEBTEDNESS INDEBTEDNESS (Enter this figure in (Enter this figure in item 15, column C item 15, column D on page 48.) on page 48.) Initials Gaming Agency Date -~PHDMJ061901 SCHEDULE “O” - CONTINGENT LIABILITIES 74. List below the information requested with regard to all contingent liabilities for which you, your spouse or your dependent children are obligated. CHECK IFOWED BY F OBLIGATION MOUNT O MOUNT O SPOUSE NAME AND ADDRESS DATE ACCOUNT PRIMARY OF OBLIGATION AMOUNT OF peek ORDEPENDENT OF CONTINGENT INCURRED NUMBER DEBTOR INCLUDING NATURE CONTINGENT CONTINGENT CHILD CREDITOR OF SECURITY, OBLIGATION OBLIGATION IF ANY $ $. TOTAL TOTAL AMOUNT ORIGINAL OF OUTSTANDING CONTINGENT CONTINGENT LIABILITIES LIABILITIES (Enter this figure in (Enter this figure in item 16, column C item 16, column D - on page 48.) on page 48.) Initials Gaming Agency Date e - PHDMJ061901 rf 75. Provide the names and other info rmation requested of three (3) references over the age of 18 who have known you for at least one year and can attest to your good character and reputation. No person can be a reference who is a member of your family. (Spouse, parents, grandparents, children, grandchildren, siblings, uncles, aunts, nephews, nieces, fathers-in-law, mothers-in-law, sons-in-law, daughters-in-law, brothers-in-law and sisters-in- law whether by whole or half blood, by marriage, adoption or natural relationship.) REFERENCE ONE Name MAILING Address Address Telephone No. Occupation REFERENCE TWO Name How long have you known the reference? Address MAILING Address Telephone No. Occupation How long have you known the reference? REFERENCE THREE Name MAILING Address Address Telephone No. Occupation Initials Gaming Agency How long have you known the reference? ' Date PHDMJ061901 e ty) 76. As indicated in the instructions on page 2 of this form, this page is to be used by you for any questions which require additional Space to answer. The number of the question must be Stated immediately prior to your answer. If additional pages are needed, photocopy this page or add paper of similar size and identify these pages with corresponding numbers and letters. You must use blue ink to personally initial, date and identify the gaming agency to which your application is being submitted at the bottom of any new page added. IDENTIFY ALL ANSWERS BY ORIGINAL QUESTION NUMBERS SSE ALL ANSWERS BY ORIGINAL QUE USE ADDITIONAL PAGES IF NECESSARY SEE PAGED IF NECESSARY Date Page 65 Initials Gaming Agency PHDMJ061901 STATEMENT OF TRUTH STATE OF ) ) Ss. COUNTY OF + , being duly swom according to law deposes and says: (Print Name ) (Place your initials in appropriate response.) L. Tam the applicant who is submitting this application form. 2: I personally supplied the information contained in this form. 3; I swear/affirm that the information contained in this form is true to the best of my knowledge and belief. 4. I swear/affirm that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are willfully false, I am subject to termination and/or punishment. (SIGNATURE OF APPLICANT) Interpreter’s Name Interpreter’s Signature Language spoken, if not English SUBSCRIBED and sworm to before me this day of , 20 NOTARY PUBLIC Commission Expiration Date RELEASE AUTHORIZATION To All Courts, Probation Departments, Selective Service Boards, Employers, Educational Institutions, 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 Control Commission (Print Applicant Name) and/or The Department of Justice Division of Gaming to conduct a full investigation into my background and activities. Therefore, you are hereby authorized to release any and all information pertaining to me, documentary or otherwise, as requested by any employee or agent of the U. S. Virgin Islands Casino Control Commission and/or The Department of Justice Division of Gaming, provided that he or she certifies to you that I have an application pending before the U. S. Virgin Islands Casino Control Commission, or that I am presently a licensee, registrant or person required to be qualified under the provisions of the applicable U. S. Virgin Islands Casino Control Commission's Regulations. 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. Date: (Signature of Applicant) Date of Birth: Social Security #: SUBSCRIBED and sworn to before me this day of , 20 NOTARY PUBLIC Commission Expiration Date 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 US. Virgin Islands, its instrumentalities and agents, including the U.S. Virgin Islands Casino Control Commission, its members, agents, and employees, from any and all manner of actions, causes of actions, suites, 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. L the undersigned, having read this release, execute it (Print Name) voluntarily with full knowledge of its significance. Date: SIGNATURE OF APPLICANT Date of Birth: Social Security #: SUBSCRIBED and SWORN to before me this day of , 20 NOTARY PUBLIC Commission Expiration Date