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MUL Tl JURISDICTIONAL PERSONAL HISTORY DISCLOSURE FORM 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 KEY EMPLOYEE LICENSE APPLICANT CHECKLIST  Multi-Jurisdictional PHD Form. Applicant must answer every question completely  Statement of Truth, Release of all Claims, and Release Authorization must be notarized THE FOLLOWING DOCUMENTATIONS 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  Offer letter  Tax documents (last 3 years)  Social Security Card  High School Diploma or notarized statement indicating why one cannot be provided THE FOLLOWING DOCUMENTATION ARE REQUIRED FOR RENEWAL APPLICATION  Multi-Jurisdictional PHD Form. Applicant must answer every question completely  Fingerprint card  Background check  2 passport size pictures  Tax documents (last 3 years) MUL Tl JURISDICTIONAL PERSONAL HISTORY DISCLOSURE FORM This application is designed to allow applicants for casino/gaming qualification to complete one fonn 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 fonn as an 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 fonn and all supplemental forms used by the jurisdictions accepting this form may be found on the Internet at vvww.iagr.org APPLICATION INSTRUCTIONS PLEASE READ ALL INSTRUCTIONS CAREFULLY BEFORE COMPLETING THIS FORM. I. COMPLETING THIS FORM: a. 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. b. 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. c. 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. d. 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. e. If the space available is insufficient to respond to a question, you are to supply the required information on an attachment page and dearty 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. f. 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. Initials _____ Gaming Agency __________________________ Date_____________ PHDMJ061901 II. BE SURE TO: a. Attach a recent within the past six months color photograph of yourself in the space provided on page 5. b. 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. c. 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. Ill. BEFORE YOU SUBMIT THIS FORM TO THE GAMING AGENCY TO WHICH YOU ARE APPLYING, BE SURE THAT: a. You have reviewed the particular gaming agency's filing instructions for the type of license, approval or qualification that you are seeking. b. You have included all required attachments listed in this form. c. The Statement of Truth form is notarized on the original application. d. Every question has been answered completely. e. You retain a completed copy of your application package for your own records. f. You have completed any ancillary forms for the individual jurisdictions. IV. TIPS FOR COMPLETING THIS FORM: a. 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. b. 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. c. 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. d. 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. Initials.____________ Gaming Agency __________________________________ Date. ______________ PHDMJ061901 MUL Tl 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) MAILING ADDRESS/POSTAL ADDRESS: NUMBER AND STREET APT #/FLAT# FIRST CITY/TOWN HOME ADDRESS: (IF DIFFERENT THAN MAILING ADDRESS/POSTAL ADDRESS) NUMBER AND STREET PRESENT BUSINESS ADDRESS: NUMBER AND STREET APT #/FLAT# CITY/TOWN MIDDLE STATE/PROVINCE ST A TE/PROVINCE STA TE/PROVINCE HOME TELEPHONE NUMBER: (AREA CODE) (NUMBER) CURRENT BUSINESS TELEPHONE NO. AT PLACE OF EMPLOYMENT: (AREA CODE) (NUMBER) (EXTENSION) DATE OF BIRTH: (MO)(DAY)(YEAR) E-MAIL ADDRESS (OPTIONAL): ZIP/POSTAL CODE ZIP/POSTAL CODE ZIP/POSTAL CODE FAX NUMBER: (AREA CODE) (NUMBER) HAVE YOU BEEN KNOWN BY ANY OTHER NAME OR NAMES? YES O NO O 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 WEIGHT __ FT IN/ __ CM LBS/ KG -- DO YOU HAVE ANY SCARS, TATOOS, OR OTHER DISTINGUISHING MARKS AND/OR CHARACTERISTICS? IF SO, PLEASE DESCRIBE. PHDMJ061901 Initials__________ Gaming Agency______________________ Date ____________ CITY/TOWN APT #/FLAT# _______ _______ ________________ ___________________ _____________________ PHDMJ061901 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 ____________ 1. A.Please indicate: 1. 2. 3. 2. Have you ever been issued a passport? If yes, provide the following information about your passport(s): PASSPORT NUMBER COUNTRY OF ISSUE PLACE ISSUED DATE ISSUED PHDMJ061901 Yes O No O EXPIRATION DATE Place of birth Date of birth Day Month Year City/Town State/Province Country Country of birth Initials_________ Gaming Agency________________________________ Date____________ Of what country are you a citizen ?? 3. Beginning with your current residence(s) and working backward, provide the following information with respect to each place where you have lived (including residences while attending college or while in military service) during the past fifteen (15) years or since the age of 18, whichever is less. DATES NAME, ADDRESS & TELEPHONE NO. OF LANDLORD OR FROM: TO: ADDRESS OWN OR RENT (MO/YR\ (MO/YR) (NO .. STREET. APT#/FLAT#, CITYfTOWN. STATE/PROVINCE. COUNTRY & ZIP/POSTAL CODE) MORTGAGE/BONO HOLDER, IF KNOWN PHDMJ061901 Initials_________ Gaming Agency________________________________ Date____________ ____________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ ____________________________________________________________________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ ___________________________________________________________________ _____________________________________________________________________ _ 4. What is your current marital status: Single D How many times have you been married? A. CURRENT MARRIAGE Name of Spouse: MIDDLE MAIDEN FIRST Spouse's Occupation: ________________________________ Date of Birth: Month Year Place of Birth: ---"" DAY Home Address: AREA CODE B. PREVIOUS MARRIAGES Provide the information below regarding your previous marriages: (Do NOT include current spouse.) NAME OF FORMER SPOUSEL) DA TE AND PLACE (INCLUDE MAIDEN NAME, IF DATE OF OF MARRIAGE BIRTH APPLICABLE) IF ANNULLED, SEPARATED DOCKET/CASE # OR DIVORCED .. INDICATE PRESENT ADDRESSES OF FORMER SPOUSE(S) DATE AND JURISDICTION OF DIVORCE (NO., STREET, APT#/FLAT#, CITYfTOWN, WHERE SUCH ACTION WAS ACTION (IF STATE/PROVINCE, COUNTRY, TAKEN KNOWN) ZIP/POSTAL CODE) Initials____ PHDMJ061901 _________________________________ Provide the information below regarding your current marriage and spouse: STREET CITY/TOWN STATE/PROVINCE ZIP/POSTAL CODE Gaming Agency _________________________________ Date______________________ Married Legally Separated Divorced Widow/Widower Engaged Family Data ___________________________________ __________________________________________________________ CITY/TOWN STATE/PROVINCE Telephone Number: ____________________________ COUNTRY NUMBER ADDRESS NAME DATE OF BIRTH BIRTH PLACE (NO .. STREET. APT., CITY, STATE, COUNTRY, ZIP CODE) 5.b. Please mark the appropriate response regarding your child support obligations: D I am not subject to a court order for the support of a child. AMT. OF SUPPORT (IF A DEPENDENT) D I 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 D I 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 _________________________________________________ Gaming Agency _________________ Date __________ Initials _______ PHDMJ061901 Address________________________________________________________________________________ Contact ________________________________________________________________________________ 5. a. In the chart below, list the names of all your children, step-children and adopted children and the amount of support, if dependent. Also list all other persons who you are supporting or contributing to the support of, and provide the amount of support. NAME DATE OF BIRTH PHONE NUMBER OCCUPATION (INCLUDE MAIDEN) ADDRESS (NO .. STREET, APT#/FLAT#, CITYfTOWN. STATE/PROVINCE, COUNTRY, ZIP/POSTAL CODE) Father: Mother: Father-in-law: Mother-in-law: Former Parents-in-law•: • For former parents-in-law only provide names. Initials _______ Date____________________________ PHDMJ061901 Gaming Agency _______________________________________ 6. List names, residence addresses, dates of birth, and most recent occupations of parents, parents-in-law, former parents-inlaw * , or legal guardians, living or deceased. If retired or deceased, list last address and occupation: 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 DA TE OF BIRTH PHONE NUMBER OCCUPATION (INCLUDE MAIDEN) ADDRESS (NO .. STREET, APT#/FLAT#, CITY/TOWN, STATE/PROVINCE. COUNTRY. ZIP/POSTAL CODE) Sibling: Spouse: Sibling: Spouse: Sibling: Spouse: Sibling: Spouse: Sibling: Spouse: Sibling: Spouse: Sibling: Spouse: Initials_____________ PHDMJ061go1 Gaming Agent ___________________________ Date ________________ 8. Period(s) of Active Service: From:__________________________________ To: ._________________________________ 9. Date and type of discharge or separation (Honorable, Dishonorable, Honorable Conditions, Medical, etc.) from Military Service(s Yes D No D Initials Gaming Agency Date CHARGE OR ARREST SENTENCE _______ ____________________ ________ PHDMJ061901 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 If yes, provide the following information: Country of Service: _________________________________________________________________________________________ Branch of Service: ______________________________________ Service Serial #: _________________________________ Highest Rank Held:____________________________________________ MILITARY SERVICES From:__________________________________ To: ._________________________________ 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 owing 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? NATURE OF CHARGE OR ARREST NAME OF MILITARY ORGANIZATION FILING CHARGES DISPOSITION (CONVICTED, ACQUITTED, DISMISSED, PLEADING, ETC.l "In the United States a military record is called a DD214. If you have served in the US military,you should provide a copy of this record. If your military service was in another country, you should provide a copy of whatever official documentation was provided to you at the time of your discharge. "Charges filed aganist you by the military authorities in any country would fall under the code of Military Justice to that jurisdiction. In the United States, this means any charges filed against you under Article 15 of the Uniform of Military Justice applicable to that jurisdiction (summary court, deck,court, captain's mast, company punishment, etc.) 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. DATES GRADUATED FROM: TO: NAME AND ADDRESS OF SCHOOL, TRAINING PROGRAM, ETC. DESCRIPTION OF EDUCATION PROGRAM YES OR NO (MO/YR) (MO/YR) LIST ANY DEGREE OR CERTIFICATION ATTAINED Initials _________ _________________ Date________ PHDMJ061901 Gaming Agency 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 (MO/YR) (MO/YR) NAME AND ADDRESS OF FIRM, CORPORATION, ASSOCIATION, PARTNERSHIP OR OTHER BUSINESS ENTITY COMPENSATION RECEIVED Initials ___________ PHDMJ061901 Gaming Agency_____________ Date _______ DATES TITLE OF OFFICE OR POSITION HELD NAME AND ADDRESS OF FIRM, CORPORATION, COMPENSATION FROM: TO: ASSOCIATION, PARTNERSHIP OR OTHER BUSINESS ENTITY RECEIVED (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 TO: NAME AND ADDRESS OF (MO/YR) GOVERNMENT AGENCY/ORGANIZATION Initials _______ Gaming Agency_____________________________ Date ______________ PHDMJ061901 TITLE OF OFFICE OR POSITION HELD COMPENSATION RECEIVED FROM: (MO/YR) * 14. Have you ever been employed by a casino or gaming/gambling related company in any jurisdiction? Yes O No O *Casino or gaming/gambling related company includes any form or type of casino, gaming/gambling related operation, any manufacturer of gaming/gambling equipment, junket enterprise, horse racing, dog racing, pari-mutuel operation, lottery, sports betting, Internet gaming, etc. DATES NAME OF SUPERVISOR REASON FOR LEAVING FROM TO TITLE/POSITION HELD AND DESCRIPTION OF DUTIES NAME OF GAMING/GAMBLING GAMING REL.A TED COMPANY AND COUNTRY/STATE WHERE YOU WERE EMPLOYED NAME, MAILING ADDRESS AND TELEPHONE NUMER OF EMPLOYER(S) (MO/YR) (MO/YR) __________________ ____ Initials ______ PHDMJ061901 Gaming Agency Date 15. In the chart below, provide the information regarding your employment for the past twenty years or from age 18, whichever is less. Begin with your present job and work backwards. Give dates of any unemployment between jobs in proper sequence. Include all part-time and full-time employment and any military service. For any casino or gaming/gambling related employment identified in the previous question, you are only required to fill in the dates of employment and the name of the casino or gaming/gambling related company on this chart. DATES NAME OF FROM: TO: NAME. MAILING ADDRESS. AND TELEPHONE NUMBER OF EMPLOYER(S) TITLE/POSITION HELD AND DESCRIPTION OF DUTIES SUPERVISOR REASON FOR LEAVING/ COMPENSATION AT DEPARTURE (MONR) (MONR) Initials ______ PHDMJ061901 Gaming Agency __________________________ Date _____________ 15. Contd DATES NAME OF FROM: TO: NAME. MAILING ADDRESS. AND TELEPHONE NUMBER OF EMPLOYER(S) TITLE/POSITION HELD AND DESCRIPTION OF DUTIES SUPERVISOR REASON FOR LEAVING/ COMPENSATION AT DEPARTURE (MONR) (MONR) Initials ______ PHDMJ061901 Gaming Agency __________________________ Date _____________ If additional space is needed,please provide a attachment. a. Were you ever discharged, suspended or asked to resign from employment? b. During the last ten year period, were you ever charged with any infraction in relation to any employment which was the subject of any disciplinary action? Yes D Yes O No D No O If yes to either question, complete the following chart as to each such time you were discharged, suspended, asked to resign or disciplined: NAME OF NAME AND ADDRESS OF EMPLOYER DATE OF DISCHARGE, SUSPENSION, RESIGNATION OR DISCIPLINARY ACTION SUPERVISOR REASON FOR DISCHARGE, SUSPENSION, RESIGNATION OR DISCIPLINARY ACTION Initials _____ PHDMJ061901 Gaming Agency________________________ Date_________ • DATES FROM: TO: NAME. ADDRESS AND TELEPHONE NUMBER OF EMPLOYER (MO/YR) (MO/YR) TITLE/ POSITION HELD 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 O No O If yes, complete the following chart: DATES FROM: TO: CAPACITY INCOME RECEIVED FOR WHOM HELD (MO/YR) (MO/YR) NATURE OF TRUST OR OTHER FUND Gaming Agency ________________ Date _________ Initials _______ PHDMJ061901 17. List any and all compensated employment, of whatever nature, held by your spouse during the past twelve month period. Begin with your spouse’s current employer. • Yes D No D 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. Yes D No D If yes, complete the following chart: DATES NAME ON LICENSE TYPE OF LICENSE FROM: TO: (MO/YR) (MO/YR) NAME AND ADDRESS OF LICENSING AGENCY/ORGANIZATION DISPOSITION OF THE APPLICATION Gaming Agency ________________ _________________________ Date ______________________ Initials ____ _______ PHDMJ061901 19. a. Have you or your spouse ever sought and been denied a position as a trustee or other fiduciary officer ? b . Have you or your spouse ever been suspended or removed from a position as a trustee or other fiduciary officer ? Yes D No D If yes to either question, complete the following chart: 21. Yes D No D TYPE OF LICENSE. PERMIT OR CERTIFICATE NAME & ADDRESS OF GOVERNMENTAL AGENCY/ORGANIZATION DATE OF DENIAL, SUSPENSION. REVOCATION OR CONDITION REASON(S) FOR DENIAL 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 D No O If yes, complete the following chart as to each denial, suspension or revocation: TYPE OF REASON(S) NAME OF ENTITY LICENSE, TYPE OF DATE OF POSITION HELD BY YOU OR YOUR SPOUSE PERMIT OR ACTION TAKEN ACTION FOR CERTIFICATE NAME AND ADDRESS OF GOVERNMENT AGENCY/ORGANIZATION TAKING ACTION ACTION Gaming Agency ________________________________________ Date ___________________ Initials ______ PH!)MJ061901 Have any of the licenses,permits or certifications applied for,or held by you or your spouse, as identified in the previous question ever been denied, suspended, revoked or subject to any conditions in any Jurisdiction? If yes, complete the following chart as to each denial, suspension, revocation or conditions: • • 23. List any group, firm, partnership, corporation or any other businesses in which you have held an ownership interest of 5% or more for the past twenty years, or since the age of 18, whichever is less. (Do not include publicly traded corporations in which you owned stock.) DATES FROM: TO: %INTEREST (MO/YR) (MO/YR) NAME(S) & ADDRESS(ES) OF BUSINESS(ES) CURRENT ST A TUS OF BUSINESS(ES) HELD BY NAME(S) OF OTHER OWNERS ADDRESS(ES) OF OTHER OWNERS YOU STATE/PROVINCE AND COUNTRY OF ORGANIZATION OR INCORPORATION Initials ____ PHDMJ061901 Gaming Agency__________________________ Date ____________ 24. Have you or has your spouse ever made application for, or held, a license, permit, registration, finding of suitability, qualification or other authorization to participate 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 O No O If yes, complete the following chart: DATE OF APPLICATION NAME & ADDRESS OF LICENSING AGENCY/ORGANIZATION (INCLUDING COUNTRY, STATE/PROVINCE. COUNTY OR MUNICIPALITY/TOWN) TYPE OF LICENSE. PERMIT, APPROVAL OR REGISTRATION DISPOSITION (GRANTED, DENIED OR PENDING, ETC.) LICENSE, PERMIT, APPROVAL OR REGISTRATION NUMBER Initials ____________ PHDMJ061901 Gaming Agency_______________________________ Date ______________ 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 O No O If yes, complete the following chart: NAME AND ADDRESS OF LICENSING AGENCY OR COMMISSION DATE OF APPEARANCE(S) NATURE OF HEARING WAS TESTIMONY GIVEN? Initials PH'.)MJ061901 Gaming Agency___________________________________ Date ___________ __________ Yes D No D DATE OF NAME AND ADDRESS OF BUSINESS ENTITY NATURE OF YOUR INTEREST APPLICATION NAME & ADDRESS OF LICENSING AGENCY TO WHICH APPLICATION WAS MADE TYPE OF LICENSE APPLIED FOR DISPOSITION OF APPLICATION PHDMJ061901 Gaming Agency___________________________________ Date ___________ 26.To the best of your knowledge, in the past twenty years or since the age of 18, whichever is less, have you held a direct or indirect financial or ownership interest in any group, firm, corporation, partnership or other business entity that has applied to any licensing agency in any jurisdiction for any license, permit, registration, finding of suitability, or qualification in connection with any form or type of a 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? (Do not include publicly traded corporations or entities in which you held less than 1 % of the stock.) If yes, complete the following chart: Initials __________ Yes D No D b. Do you or any members of your family (spouse, parents, grandparents, children, grandchildren, siblings, uncles, aunts, nephews, nieces,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? If yes to either question, complete the following chart: NAME OF PERSON RELATIONSHIP NAME OF GAMING/GAMBLING OR ALCOHOLIC BEVERAGE BUSINESS AND ADDRESS Yes D No D BUSINESS TELEPHONE Gaming Agency___________________________________ Date ___________ 27.a. Are any members of your family (spouse, parents, grandparents, children, grandchildren, siblings, uncles, aunts, nephews, nieces, fathers-in-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) associated with or employed in any form or type of casino or gaming/gambling related operation as defined inquestion 26 in any jurisdiction? Initials __________ PHDMJ061901 DEFINITIONS: INSTRUCTIONS: Initials 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." 1. Answer "YES" and provide all information to the best of your ability EVEN IF: A. You did not commit the offense charged; B. The charges were dismissed or subsequently downgraded to a lesser charge; C. You completed a Pretrial Intervention (PTI) or equivalent diversionary program in other jurisdictions; D. You were not convicted; E. You did not serve any time in prison or jail; or F. The charges or offenses happened a long time ago. relating to a charge, an arrest or conviction have been expunged or otherwise officially sealed by a . 2. Answer "NO" IF any records court or government agency * Some jurisdictions permit the.gaming ag:ncy to obtain inf)rmation about the expungement or sealing order as part of the licensing _______ PHDMJ061901 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. Gaming Agency___________________________________ Date ___________ 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. CIVIL, CRIMINAL AND INVESTIGATORY PROCEEDINGS 28. Have you ever been arrested or charged with any crime or offense in any jurisdiction? Yes D No D If yes, complete the following chart: NATURE OF CHARGE OR OFFENSE/ LOCATION OF WHERE INCIDENT OCCURRED DATE OF CHARGE OR OFFENSE SENTENCE NAME AND ADDRESS OF LAW ENFORCEMENT AGENCY OR COURT INVOLVED DISPOSITION (CONVICTED, ACQUITTED, DISMISSED, PENDING, PARDONED, ETC.) Initials _________ PHDMJ061901 Gaming Agency___________________________________ Date ___________ Yes O No O NAME AND ADDRESS OF NATURE OF PROCEEDING DATE GOVERNMENTAL AGENCY/ORGANIZATION INVOLVED Yes D No D NAME AND ADDRESS OF NATURE OF PROCEEDING WAS TESTIMONY DATE ON WHICH APPROXIMATE COURT OR OTHER AGENCY OR INVESTIGATION GIVEN? TESTIMONY TIME PERIOD OF WAS GIVEN INVESTIGATION Initials. _____ ______ PHDMJ061901 Gaming Agency ______________________________ Date ____________ To the best of your in knowledge,has a criminal indictment,information or complaint ever been filed or returned against you, but for which you were not arrested or in which you were named as an unindicted party or unindicted co-conspirator in any criminal proceeding in any jurisdiction? If yes, complete the following chart: 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? 29. If yes, complete the following chart: Yes D No D NAME AND ADDRESS OF COURT OR OTHER AGENCY/ORGANIZATION NATURE OF PROCEEDING OR INVESTIGATION WAS TESTIMONY GIVEN? DATE ON WHICH TESTIMONY WAS GIVEN APPROXIMATE TIME PERIOD OF INVESTIGATION Yes D No D DATE OF PARDON, DISMISSAL, SUSPENSION, TYPE OF ACTION TAKEN NAME AND ADDRSS OF GOVERNMENT AGENCY/ORGANIZATION GRANTING PARDON, DISMISSAL OR DEFERAL SUSPENSION OR DEFERAL Gaming Agency________________________ Date _______________ a. Have you ever been called to testify before, or otherwise been questioned, interviewed, deposed, or requested to take a polygraph exam by any governmental 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? b. Have you ever been subpoenaed to appear or testify before a federal, national, state, county grand jury, or other criminal investigatory agency or body, or any board or commission, or any civil, criminal or administrative proceeding or hearing? If yes to either question, complete the following chart: Yes No 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? If yes, complete the following chart: Initials __________ PHDMJ061901 31 33. Has your spouse or any of your children, step-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 O No O If yes, complete the following chart: NATURE OF DATE OF NAME OF PERSON RELATIONSHIP CHARGE OR CHARGE OR SENTENCE OFFENSE OFFENSE NAME & ADDRESS OF LAW ENFORCEMENT AGENCY OR COURT INVOLVED DISPOSITION (CONVICTED, ACQUITIED, DISMISSED, PENDING, PARDONED, ETC.) Initials __________ PHDMJ061901 Gaming Agency_______________________________ Date_____________ 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 O No O If yes, complete the following chart: DATE DOCKET/CASE OTHER PARTIES TO SUIT NATURE OF SUIT DISPOSITION DATE OF FILED NAME & ADDRESS OF COURT NUMBER DISPOSITION Initials______ PHDMJ061901 Gaming Agency_______________________________ Date___________ 35. In the past fifteen (15) years, has any general partnership, business venture, sole proprietorship or closely held corporation, which you were associated with as an owner, officer, director or partner, been a party to a lawsuit, arbitration or bankruptcy? Yes D No O If yes, complete the following chart: NAME OF ENTITY TYPE OF ENTITY APPROXIMATE DATE(S) OF LAWSUIT/ARBITRATION/BANKRUPTCY WHERE ACTION FILED (CITY/TOWN, STATE/PROVINCE, COUNTY) Initials ____ PHDMJ061901 Gaming Agency_______________________ Date________ 36. In the past ten years, have you been cited or charged with, or formally accused of, any violation of a statute, regulation or code of any local, t state, county, municipal, provincial, federal or national government other than a criminal, disorderly persons, pety disorderly If yes, complete the following chart: Yes D No D GOVERNMENTAL AGENCY/ORGANIZATION NATURE OF CHARGE DATE DISPOSITION Initials _________ PHDMJ061901 person or motor vehicle violation? Gaming Agency________________________________ Date__________ Yes O No O If yes, complete the following chart: .GAMING/GAMBLING AGENCY DATE OF EXCLUSION REASON FOR EXCLUSION VEHICLE OPERATOR DATA 38. _ _ to you in any Junsdiction: In the chart below list all current motor vehicle operator licenses (automobiles, motorcycles, airplanes, boats ' recreational vehicles ' etc) issued DATE LAST ISSUED LICENSE NUMBER TYPE OF LICENSE JURISDICTION ISSUING LICENSE EXPIRATION DATE OF LICENSE Gaming Agency__________________________ Date______________ Initials _____ PHDMJ061901 37.Have you ever been barred or otherwise excluded, for any reason, other than for the denial, suspension or revocation of a license or registration, from any form or type of casino or gaming/gambling related operation in any jurisdiction? (Check "YES" even if the disbarment or exclusion is no longer in effect or has been lifted.) Yes D No D NATURE OF LIEN/DEBT WHEN FILED WHERE FILED CURRENT STATUS Initials__________ PHDMJ061901 FINANCIAL DATA 39. Have any individual, local, city, county, provincial, state, Federal, national, or any other governmental liens/debts been filed against you as an individual, sole proprietor, member of a partnership, or owner of a corporation in any jurisdiction? If yes, complete the following chart: Gaming Agency __________________________ Date _________ Yes D No D DOCKET/CASE NUMBER NAME AND ADDRESS OF COURT NAME AND ADDRESS OF TRUSTEE DATE FILED 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 D No D If yes, complete the following chart: DATE DOCKET/CASE NAME AND ADDRESS OF COURT NAME AND ADDRESS OF FILING PARTY NAME AND ADDRESS OF TRUSTEE FILED NUMBER Initials ______ 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? If yes, complete the following chart: Gaming Agency____________________________________ Date _____________ Yes O No O If yes, complete the following chart: PRESENT STATUS NAME AND ADDRESS OF BUSINESS ENTITY YOUR RELATIONSHIP TO BUSINESS ENTITY REASON PLACED UNDER LIQUIDATION, RECEIVERSHIP, ETC. DATE PLACED UNDER LIQUIDATION, RECEIVERSHIP, ETC. 43. Have your wages, earnings, or other income been subject to garnishment, attachment, charging order, voluntary wage execution or the like during the past ten year period? Yes D No D If yes, complete the following chart: DATE DOCKET/CASE NAME AND ADDRESS OFCOURT NATURE OF AMOUNT OF FILED NUMBER OBLIGATION OBLIGATION NAME AND ADDRESS OF HOLDER OF OBLIGATION Gaming Agency ______________________________ Date_________ Initials________ PHDMJ061901 42. Have you as an individual, member of partnership, or owner, director or officer of a corporation ever been in a busisness entity that has been in liquidation, receivership or been placed under some form of govermental administration or monitoring ? 44. In the past ten years, have you ever had any property, real or personal, repossessed by a finance company in any jurisdiction ? Yes D No D If yes, complete the following chart: TYPE OF PROPERTY DATE REPOSSESSED NAME AND ADDRESS OF COMPANY 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. A settlor/grantor, beneficiary or trustee of any trust? If yes, complete the following chart as to each estate and trust: Yes D No D NAME AND LOCATION OF ESTATE/TRUST POSITION/ INTEREST HELD DATE(S) ON WHICH POSITIONS WERE HELD OR INTEREST WAS RECEIVED AMOUNT OF COMPENSATION OR NATURE AND VALUE OF BENEFIT GRANTED/RECEIVED Initials________ PHDMJ061901 Gaming Agency____________________________________ Date _______________ Yes O No O DESCRIPTION OF TRUST LOCATION OF TRUST NAME OF TRUSTEE(S) Yes D No O DESCRIPTION OF TRUST LOCATION OF TRUST NAMES OF OTHER(S) WITH INTEREST IN TRUST Initials ______ PHDMJ061901 46.Do you own, hold, or have an interest in any assets in a trust in any jurisdiction? (You may exclude those assets disclosed in your answer to question 45). If yes, complete the following chart: 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 person or entity in any jurisdiction? (You may exclude those assets or liabilities disclosed in your answer to question 45). If yes, complete the following chart: Gaming Agency_________________________________ Date______________ Yes D No D If yes, complete the following chart: DATES ACCOUNT NUMBER FROM: TO: NAME AND ADDRESS OF INSTITUTION HOLDING ACCOUNT (MO/YR) (MO/YR) NAME AND ADDRESS OF EACH PERSON/ENTITY APPEARING ON THE ACCOUNT PRESENT AMOUNT HELD/ AMOUNT HELD BEFORE CLOSING Initials __________ 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? Gaming Agency______________________________ Date ____________ Yes D No D DESCRIPTION OF ASSET/LIABIITY LOCATION OF ASSET/LIABILITY 49. During the last ten year period, have you or has your spouse or any of your children, while dependent, received a loan in excess of $25,000USD? (If you are applying in a jurisdiction other than the United States. the amount you are required to report is the equivalent to $25,000USD in the national currency of the jurisdiction where you will be filing this application.) Yes D No O If yes, complete the following chart: DATE ORIGINAL INTEREST TERMINATION RECEIVED NAME AND ADDRESS OF LENDER NAME OF BORROWER AND ALL CO-SIGNERS AMOUNT RATE DATE LOAN OF LOAN (%) OF LOAN 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: 50. During the last ten year period, have you or has your spouse or any of your children, while dependent, made any loan in excess of $10,00 USD ? (If you are applying in a jurisdiction other than the United States, the amount you are required to report is the equivalent of $10,00 USD in the national currency of the jurisdiction where you will be filing this application.) If yes, complete the following chart: Yes D No D DATE OF LOAN NAME AND ADDRESS OF BORROWER ALL CO-PARTIES TO LOAN NAME OF LENDER ORGINAL AMOUNT OF LOAN INTEREST RATE (%) TERMINATION OF LOAN SECURITY PLEDGED 51 . Have you individually ever exchanged currency in an amount of more than $10 ,000 USD 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 S 10,000 USD in the national currency of the jurisdiction where you will be filing this application.) If yes, complete the following chart: Yes D No D DA TE ANO AMOUNT OF EXCHANGE LOCATION WHERE EXCHANGE MADE REASON FOR EXCHANGE DID YOU FILL OUT OR FILE ANY GOVERNMENTAL REPORTING DOCUMENT Initials ___ PHDMJ061901 Gaming Agency ________________ ____________ Date_________ 52.Do you maintain a brokerage or margin account with any securities or commodities dealer ? If yes, complete the following chart : Yes D No D 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 $100,000 USD 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 $100,000 USD in the national currency of the jurisdiction where you will be filing this application.) If yes, complete the following chart : Yes D No D DATE OF CLAIM NATURE OF CLAIM NAME AND ADDRESS OF INSURANCE CARRIER DISPOSITION Initials ___ PHDMJ061901 Gaming Agency ________________ ____________ Date_________ DESCRIPTION OF GIFT NAME OF THE DONOR OR DONEE DATE GIFT GIVEN/RECEIVED 55. a. Do you have any safe deposit boxes in your name in any jurisdiction? b. Do you have access to the funds in any other safe deposit boxes in any jurisdiction? If yes to either question, complete the following chart: NAME AND ADDRESS OF BANK OR OTHER INSTITUTION/BUSINESS WHERE LOCATED NAME(S) IN WHICH ACCOUNT(S) OR SAFE DEPOSIT BOX(ES) HELD TYPE OF ACCOUNT, (SAVINGS, CHECKING, SAFE DEPOSIT, ETC.) Gaming Agency _____________________________ Date ___________ Initials _________ PHDMJ061901 Yes D No O APPROXIMATE VALUE Yes O No O Yes O No O ACCOUNT NO. OR SAFE DEPOSIT BOX NO. 54. During the last five year period, have you, your spouse or dependent children given or received any gift or gifts, whether tangible or intangible which either individually or in the aggregate exceeded $10,000 USD in value in any one 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 $10,000 USD in the national currency of the jurisdiction where you will be filing this application.) If yes, complete the following chart as to each gift : 56. In the past ten years, or since the age of 18, whichever is less, have you received any referral or finder's fee in excess of $1 0,000USD (II you are applying in a jurisdiction other than the United Stales, the amount you are required to report Is the equivalent of $10,000USO. In the national cum,ncy of the Juri&dlctlon where you will be filing this application.) Yes D No D If yes, complete the following chart: NAME AND ADDRESS NATURE OF GOODS OR AMOUNT RECEIVED DATE RECEIVED OF ALL PARTIES INVOLVED SERVICES PROVIDED 57. Have you, in the past ten years or since the age of 18, whichever is less, given a guarantee, co-signed or otherwise insured payment of a loan, debt or other financial obligation in any jurisdiction? Yes D No D If yes, complete the following chart: NATURE OF OBLIGATION DATE OBLIGATION MADE NAME(S) OF PERSON RESPONSIBLE FOR (PERSONAL GUARANTEE, ETC.) OBLIGATION STATUS OF UNDERLYING OBLIGATION Initials ____ _ Gaming Agency __________ _;__ _____ _ Date--------- Page47 PHOMJ0619D1 NET WORTH STATEMENT -- ASSETS AND LIABILITIES NOTE: Complete the financial statements on pages 49 lhrough 63 and copy the totals in the appropriate space below. 59. Please list all liabillUes of you, your spouse and your dependent chidren. SB. Please list all assets, tangible and Intangible, In which a direct or indirect Interest Is held by you, your spouse or your dependent children. For each line item, 11st both the cost of the asset and the present market values as or the date or this statement unless this cannot reasonably be done, In which case any special valuatlon dale should be noted in the column provided. Detail each line entry on the appropriate schedule. COST AT DATE CURRENT SPECIAL ASSET ACQUIRED OR MARKET VALUATION 1. Cash a) On Hand b) In banlt (Schedule A) 2. Loans, Notes and Other Receivables (Schedule B) 3. Securities (Schedule C) 4. Real Estate Interests (Schedule 0) 5. Cash Value Life Insurance (Schedule E) 6. Cash Value Pension/ Retirement Funds (Schedule F) 7. Furniture and Clothing (Reasonable Estimate) 8. Vehicles (Schedule G) 9. Other (Schedule H) TOTAL ASSETS Initials . . PURCHASED (A) .. . , .. .. .. .• , . .. . - : . ' VALUE DATE, IFANY (B) . . ... a} .. .- . . . b) b) . .. : . . , ... . ., .. . . : .. . . ... .. ·•· .. Enter the amount as of the date of this statement Detail each line entJy on the appropriate schedule. LIABILITY 10. Notes Payable (Schedule I) 11. Loans and Olher Payables (Schedule J) 12. Taxes Payable (Schedule K) 13. Mortgages or Uens on Real Estate (Schedule L) 14. Loans Against lnsuranceJPenslons (Schedule M) 15. Other Indebtedness (Schedule N) TOTAL LIABILITIES - NETWORTH Total Asse1s (From Column B) less . . IT'otal Liabllitles : (From Column 0) 16. Contingent UabDlties (Schedule 0) Date of Statement ORIGINAL AMOUNT OF LIABILITY . . .. . .. .... . . (C} '• . .. ,· . . . ' ... . . .,. . . ... . :- . • .. . . . -·.· . AMOUNT OUTSTANDING (D) ., . ' :. t Please provide the name, address and phone number of the person completing this statement If It Is completed by someone other than you. Name Address Phone ----- Gaming Agency -------------- Date --------- Page48 PHDMJ061901 SCHEDULE "A" - CASH IN BANK 60. List below all bank accounts {checking, savings, time deposits, certificates of deposit, money market funds, etc.) foreign and domestic, maintained by you, your spouse or dependent children. Identify with an asterisk (*) any check writing accounts held with brokerage houses, insurance companies, etc. NAME OF PERSON(S) AND INTEREST NAME AND ADDRESS TAX IDENTIFICATION NUMBER(S) ACCOUNT RATE GENERAL NATURE DATE OF OF INSTITUTION APPEARING ON ACCOUNT NUMBER (%) OFACCOUNT BALANCE BALANCE $ TOTAL CURRENT BALANCE (Enter this figure In Item 1b, C(lfumnB on page 48.) Initials ---- PHOMJ061901 Gaming Agency ----------------- Ote ________ _ Page49 SCHEDULE "B" - LOANS, NOTES AND OTHER RECEIVABLES 61. List below all loans, notes and other receivables held by you, your spouse or dependent children. CHECK IF si HELD BY INTEREST ORIGINAL II) NATURE OF SPOUSE NAME ANO ADDRESS RATE LOAN _,!z DATE ADVANCE AND CURRENT OR OF DEBTOR (%) AMOUNT -LUZ> w DUE NATURE OF BALANCE DEPENDENT £!:2w 0 SECURITY, IF At-N O::OU 1-?i CHILO 0 ...  Q. (INDICATE IF UNSECURED\ $ $ TOTA!. ORIGINAL TOTAL CURRENT LOAN AMOUNT(S) (Enter this figure In BALANCE items 2, column A (Enter thi8 figure In on oaoe48.\ Hema 2, column B on """848.\ Initials ---- Gaming Agency_...;_ _____________ _ Date ________ _ PHDMJ061901 CHECK IF HELD BY NUMBER OF SPOUSE SECURITIES TYPE OF DATE OF OR OR SECURITY AND PRICE DEPENDENT CONTRACTS NAME OF ISSUING COMPANY OR GOVERNMENT AGENCY/ORGANIZATION AT PURCHASE CHILD HELD $ TOTAL PURCHASE PRICE (Enter this figure in item 3, column A on Page 48.) Initials _______ Gaming Agency____________________________ PHDMJ061901 REGISTERED OWNER DATE OF VALUATION CURRENT MARKET VALUE $ TOTAL CURRENT MARKET VALUE (Enter this figure in item 3, column B on page 48.) 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("). MARKET VALUE AT TIME OF ACQUISITION % OF OWNERESHIP IF GREATER THAN 5% ___________ ___________ Date _________________ CHECK IF HELD BY SPOUSE OR DEPENDENT CHILD $ Initials _______ Gaming Agency____________________________ 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 jurisdictionin 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. ________________ _________________ Date _________________ DATE ACCQUIRED/ DOWN PAYMENT TYPE OF PROPERTY LOT SIZE/ STAND NO/ SQUARE FOOTAGE OF BUILDING ADDRESS PARCEL/LOT NUMBER INDIVIDUALS OR ENTITIES SHARING INTEREST (INCLUDE % OF OWNERSHIP FOR EACH) PURCHASE PRICE OF % OWNED MONTHLY RENTAL INCOME IF ANY ESTIMATED MARKET VALUE OF% OWNED TOTAL CURRENT MARKET VALUE CURRENT (Enter this figure in item 4, column B on case 48.) TOTAL PURCHASE PRICE (Enter this figure in item 4, column A on paqe 48.) CHECK IF HELD BY SPOUSE OR DEPENDENT CHILD Initials _______ Gaming Agency____________________________ PHDMJ061901 $ SCHEDULE "E" - LIFE INSURANCE CASH VALUE 64. Indicate below the information requested with regard to the cash value of all life insurance policies held by you, your spouse or your dependent children. ___________________________ Date ______________ DATE PURCHASED INSURANCE CARRIER POLICY NUMBER BENEFICIARY(IES) FACE VALUE ANNUAL PREMIUM PAYMENT CASH SURRENDER VALUE EFFECTIVE DATE OF CASH SURRENDER VALUE TOTAL CASH SURRENDER VALUE (Enter this figure in item 5, column B on page 48.) CHECK IF HELD BY SPOUSE OR DEPENDENT CHILD $ Initials _______ Gaming Agency____________________________ PHDMJ061901 $ SCHEDULE "F" - CASH VALUE - PENSION/RETIREMENT FUNDS 65. Indicate below the information requested with regard to the cash value of all retirement/investment/pension funds* held by you or your spouse. __________________ __________________________ Date _________________ TYPE OF FUND TYPE OF SECURITIES HELD AND ACCOUNT NUMBER. IF ANY EMPLOYER INSTITUTION CUMULATIVE EMPLOYEE CONTRIBUTION CUMULATIVE EMPLOYER CONTRIBUTION CURRENT CASH VALUE EFFECTIVE DATE OF CASH VALUE TOTAL CUMULATIVE EMPLOYEE CONTRIBUTION (Enter this figure in item 6, column A on page 48.) TOTAL CURRENT CASH VALUE (Enter this figure in item 6, column B on page 48.) *If you are filing this application in the United States, the information is to include IRA, 401 Kand KEOGH plans. CHECK IF HELD BY SPOUSE OR DEPENDENT CHILD $ Initials _______ Gaming Agency____________________________ 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. _______________ $ ___________________ Date _________________ TYPE OF VEHICLE SPECIFY IF OWNED OR LEASED* DA7E OF P8RC+ASE LEASE MODEL YEAR MAKE/MODEL OF VEHICLE COST** IF OWNED, CURRENT MARKET VALUE TOTAL COST OF VEHICLE (Enter this figure In Item 8,column A on page 48.) TOTAL CURRENT CASH VALUE (Enter this figure In Item 8,column B on page 48.) *If leased, specify in this column the length of the /ease, total lease costs, down payments, monthly payments 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. CHECK IF HELD BY SPOUSE OR DEPENDENT CHILD $ Initials _______ Gaming Agency____________________________ PHDMJ061901 $ SCHEDULE "H" - OTHER ASSET 67. List below the information requested regarding all other assets, including any business investments in which any direct, indirect, vested or contingent is held by you, your spouse or your dependent children. Business interests should include, but not be limited to, joint ventures, partnerships, sole proprietorships, corporations and LLCs. Other assets should include, but not be limited to, art collections, coin collections, and antiques. _________________________ _________________________ Date _________________ COST TOTAL COST(S) OF OTHER ASSETS (Enter this figure in item 9, column A on page 48.) TOTAL CURRENT MARKET VALUE OF OTHER ASSETS (Enter this figure in item 9, column B on page 48.) NATURE OF ASSET DATE OF ACCQUISITION % OWNERSHIP OF INTEREST DATE OF VALUATION CURRENT MARKET VALUE $ Initials _______ Gaming Agency____________________________ 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. ___________________ __________________ Date _________________ CHECK IF HELD BY SPOUSE OR DEPENDENT CHILD NAME & ADDRESS OF CREDITOR ACCOUNT NUMBER, IF ANY DATE INCURRED DUE DATE INTEREST RATE (%) AMOUNT OF PERIODIC PAYMENT/ PAY PERIOD ORIGINAL AMOUNT OF NOTE TOTAL ORIGINAL AMOUNT OF NOTES PAYABLE (Enter this figure in item 10, column C on Page 48.) NATURE OF SECURITY, IF ANY TOTAL PAYMENTS TOTAL AMOUNT OF OUTSTANDING NOTES PAYABLE (Enter this figure in item 10, column D on Page 48.) OUTSTANDING AMOUNT OF LIABILITY $ Initials _______ Gaming Agency____________________________ 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. ____________________ _________________ Date _________________ CHECK IF HELD BY SPOUSE OR DEPENDENT CHILD NAME & ADDRESS OF CREDITOR ACCOUNT NUMBER, IF ANY DUE DATE INTEREST RATE (%) ORIGINAL AMOUNT OF NOTE TOTAL ORIGINAL AMOUNT OF LIABILITY (Enter this figure in item 11, column C on page 48.) NATURE OF SECURITY, IF ANY TOTAL PAYMENTS TOTAL AMOUNT OF OUTSTANDING LOANS AND OTHER PAYABLES (Enter this figure in item 11, column D on Page 48.) CURRENT AMOUNT OUTSTANDING DATE OPENED OR INCURRED NATURE OF ACCOUNT CHECK IF HELD BY SPOUSE OR DEPENDENT CHILD $ Initials _______ Gaming Agency____________________________ PHDMJ061901 $ SCHEDULE "K" - TAXES PAYABLE 70. List below the information requested with regard to all taxes payable for which you, your spouse, or your dependent children are obligated. Only real estate and income taxes need to be included _____________________ ________________ Date _________________ NATURE OF TAX TOTAL ORIGINAL TAX OBLIGATION(S} (Enter this figure in item 12, column C on Page 48.) TOTAL AMOUNT OF TAXES PAYABLE (Enter this figure in item 12, column D on Page 48.) TAXING AUTHORITY DATE AND AMOUNT OF ORIGINAL OBLIGATION FINES,PENALITIES AND INTEREST, IF ANY TOTAL AMOUNT DUE $ Initials _______ Gaming Agency____________________________ PHDMJ061901 $ SCHEDULE "L" - MORTGAGES OR LIENS PAYABLE ON REAL ESTATE 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. ___________________ _________________ Date _________________ CHECK IF HELD BY SPOUSE OR DEPENDENT CHILD DATE INCURRED TOTAL ORIGINAL MORTGAGES OR LIENS PAYABLE ON REAL ESTATE (Enter this figure in item 13, column c on page 48.) TOTAL MORTGAGES OR LIENS PAYABLE ON REAL ESTATE (Enter this figure in item 13, column D on page 48.) CURRENT MORTGAGE BALANCE NAME AND ADDRESS OF MORTGAGE OR LIEN HOLDER ACCOUNT NUMBER ORIGINAL AMOUNT OF LIABILITY DESCRIPTION / ADDRESS OF REAL ESTATE TERM OF MORTGAGE / INTEREST RATE (%) AMOUNT OF PERIODIC PAYMENT/ PAY PERIOD $ Initials _______ Gaming Agency____________________________ 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. _______________ ____________________ Date _________________ CHECK IF HELD BY SPOUSE OR DEPENDENT CHILD TOTAL ORIGINAL LIABILITY INSURANCE/ PENSION LOANS (Enter this figure in item 14, column C on page 48.) PERIODIC PAYMENT AMOUNT / PAY PERIOD TOTAL AMOUNT OUTSTANDING INSURANCE/PENSION LOANS (Enter this figure in item 14, column D on page 48.) CURRENT LOAN BALANCE INSURANCE CARRIER/ PENSION PLAN PURPOSE OF LOAN ORIGINAL AMOUNT OF LOAN INTEREST RATE (%) DATE OF LOAN CHECK IF HELD BY SPOUSE OR DEPENDENT CHILD $ Initials _______ Gaming Agency____________________________ 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. __________________ ________________ Date _________________ TOTAL ORIGINAL AMOUNT OTHER INDEBTEDNESS (Enter this figure in Item 15, column C on page 48.) TOTAL AMOUNT OUTSTANDING OTHER INDEBTEDNES (Enter this figure in Item 15, column D on page 48.) NAME AND ADDRESS OF CREDITOR INTEREST RATE (%) DESCRIPTION OF LIABILITY, TYPE OF OBLIGATION AND NATURE OF SECURITY, IF ANY DUE RATE AMOUNT OF PERIODIC PAYMENT / PAY PERIOD ORIGINAL AMOUNT OF LIABILITY OUTSTANDING AMOUNT OF INDEBTEDNESS CHECK IF HELD BY SPOUSE OR DEPENDENT CHILD $ Initials _______ Gaming Agency____________________________ 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. __________________ ________________ Date _________________ TOTAL ORIGINAL CONTINGENT LIABILITIES (Enter this figure in item 16, column C on page48.) TOTAL AMOUNT OF OUTSTANDING CONTINGENT LIABILITIES (Enter this figure in Item 16, column D on page 48.) NAME AND ADDRESS OF CONTINGENT CREDITOR DATE INCURRED ACCOUNT NUMBER CURRENT AMOUNT OF CONTINGENT OBLIGATION PRIMARY DEBTOR DESCRIPTION OF OBLIGATION INCLUDING NATURE OF SECURITY, IF ANY ORIGINAL AMOUNT OF CONTINGENT OBLIGATION 75. Provide the names and other information 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 __________________________________________________ __________________________________________________________________________ ______________________________________________________________ _________________________________________________________________________ ______________________________________________________________ __________________________________________________________________________ Initials,__________ Gaming Agency ___________________________________________ Date _______________ PHDMJ061901 How long have you known the reference? ______________________________________________ REFERENCE TWO Name_______________________________________________________________ MAILING Address ___________________________________________________ Address __________________________________________________ __________________________________________________________________________ ______________________________________________________________ _________________________________________________________________________ ______________________________________________________________ __________________________________________________________________________ Telephone ___________________________ Occupation __________________________________ Telephone ___________________________ Occupation __________________________________ How long have you known the reference? ______________________________________________ REFERENCE THREE Name_______________________________________________________________ MAILING Address ___________________________________________________ Address __________________________________________________ __________________________________________________________________________ ______________________________________________________________ _________________________________________________________________________ ______________________________________________________________ _________________________________________________________________________ Telephone ___________________________ Occupation __________________________________ How long have you known the reference? ______________________________________________ 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 USE ADDITIONAL PAGES IF NECESSARY Initials. __________ PHDMJ061901 Gaming Agency ___________________________________________ Date _______________ STATEMENT OF TRUTH STATE OF______________________ COUNTY OF ____________________ ) SS. )' Date: _____________ I _______________________________being duly sworn according to law deposes and says:: (Pr/111 Name) (Place your initials in appropriate response.) 1. 2. 3. 4. _____________________________ I am the applicant who is submitting this application form. _____________________________ I personally supplied the information contained in this form. ______________________________ I swear/affirn that the information contained in this form is true to the best of my knowledge and belief. ______________________________ 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 sworn to before me thls ____ day of ______ _ 20_____ NOTARY PUBLIC Commission Expiration Date Seal SIGN 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 (Signature of Applicant) NOTARY PUBLIC Commission Expiration Date Seal (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: _____________ Date of Birth: ________________ Social Security # ______________________________ SUBSCRIBED and sworn to before me this _______ day of _________ 20_____ 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 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. I, _______________________ the undersigned, having read this release, execute it voluntarily with full knowledge of its significance. (Print Name) SIGNATURE OF APPLICANT NOT ARY PUBLIC Commission Expiration Date Seal Date: _____________ Date of Birth: ________________ Social Security # ______________________________ SUBSCRIBED and SWORN to before me this _______ day of _________ 20_____ SIGN