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11) If you require further information or clarification of any aspect of this application, please contact the Virgin Islands Casino Control Commission at 340-718-3616 or via email at info@casinocontrolcommission.vi. 12) CASINO LICENSE APPLICATION AND REGISTRATiON FEES License Type Description Fee 10,000 sq. ft. Casino I Each Additional 5,000 ft. or portion $350,000 thereof $ 50,000 7,000 sq. ft. Casino II Each Additional 5,000 ft. or portion $150,000 thereof $ 50,000 7,000 sq. ft. Casino Ill Each Additional 5,000 ft. or portion $100,000 thereof $ 50,000 *Enterprise Zone Casino's in Other Casino Categories Christiansted and Frederiksted *VIPA Hotel Casino Development Rates to be determined by the (Act 6391) Commission *Partial Government Owned Casino Hourly rate for casino Hourly rate for casino investigations, casino key and $120.00/hour investigations employee investigations, qualifier investigations (32VIC§S10-§512} 32VIC §514 and Regulations Slot Machine License Fee §436-6.4 $260.00/unit Due: July ist Annually TBD by the Commission. Presently TBD Racino License Fee under review. 32VIC§441 and Regulation §436- Deposit: $600 Minimum 6.10 Expenses (Hourly investigation Casino Key Employee License rate of $120.00) Renewal: $400.00 Two Year initial and renewal License II. BEFORE YOU SUBMIT THIS FORM TO THE COMMISSION, BE SURE THAT: A. All attachments required in this form and in the Multi-Jurisdictional Personal History Disclosure Form are labeled with an exhibit number and included in both the original and the photocopies filed with the Commission. B. You have signed and notarized the Statement of Truth, Release Authorization, Consent to Inspections, Searches and Seizures fonns included herein, along with those that are included in the Multi-Jurisdictional Personal Disclosure Form C. You have answered every question completely. D. You initial and date each page of this form in the spaces provided. E. You retain a completed copy of this fonn for your own records. Business Entity Qlsclosure form NAME oϿ nUSIN£SS ENTITY (DO NOTAQliREVIATI:) ND me Dl It oppeors on th@Cottlflcllt@ of l11coffjoratlon, thartM, by,lЀwЁ 1mtn@nhlp ogrMmcnt, formation doeument1 or other offltlHI dotum@nt. D/B/A or Trad& Nam@(s) SOLE PROPRIETOR LIMITED LIABILITY PARTNERSHIP UNINCORPORATED ASSOCIATION CORPORATION LIMITED PARTNERSHP LIMITED LIABILITY COMPANY GENERAL PARTNERSHIP OTHER: TYPE OF BUSINESS ENTITY (CHECK ONE) PERSON TO BE CONTACTED IN REFERENCE TO THIS APPLICATION: Name and Tltl@ E·MIII Address Toluphono (Aruo Codo) Number PRINCIPAL BUSINESS ADDRESS OF THE BUSINESS ENTITY: STREET LOCATION Number/Strut City State MAILING ADDRESS (If different) Numbtr/StrHt City St1t1 COUNTRY TELEPHONE Ar@I Code Numb@r WEBSITE (URL) Fix Numbor Zll)Cod@ Zip Codo Fnx Number ADDRESS FROM WHICH THE BUSINESS ENTITY IS OR WILL BE CONDUCTING ANY BUSINESS, AS PART OF AN AGREEMENT WITH A CASINO HOTEL: STREET LOCATION Numbi!r/StrHt City State Zip Cod@ COUNTRY TELEPHONE Ar111 Codu Numbnr F8X Numt,ur D This form Is belns submitted as an lnltlal appllcatlon for a caslnollcense. O C11lno I E1t1bll1hmtnt: A ho1ol pml'idlnu n minimum ol'lQ0.1,499 r11111lifying §lcorinw unil&, a mfnhnum m& uf 1r1,ooo .1q11Rro Ђ01 ot'qunllfyine indoor public lflllCO, a essino room with a minimum ftЃR or 10.000 squRro roo1 nnd I oottvonilon, ba11que1 eonlor 1ha1 would acconunc,dnto n minimum or 1,,00 fJClliOnJ. O Clalno II E1t1bllshm1nt: A ho1ol 11rovldln11 a minimum or 200,299 qunll1Єln11 iloepi1111 unfi,, Ѕ minimum areo ot 7,000 squttro roo1 orquAlifyln11 indoor 1mblic Kpocu. banquet fncilitlІs d111t would Hi:ll(lftUOOrtn1e n minimum ofSOO porson,. and Hfl on,ilto cBslno roon1 with R minimum nrun uf7,()(J0 wqunr,i fuct or a (reesrnndln11 off,sile mhto room with n mnЇlmum 01'1.000 ,qunro fool to bu I011ntoo In 1ho hluoricnf dlmic1 oflho 1ow11 clom1 lo which tho ltotЈI IЉ loehlod, In arai:o ulrudy Oilabllshcd and In conformity whh 111lЊk blld r,iЋulx1lons pmmulllftttd by thu lflЌ1orlc l'rtJorvnllon Co111ml,.1lo11on St. C'mlK no inipTO\'Qt111m1Ѝ. •ddltk,ru, or "ltotatiom nro 10 bo mndo to 1ho eЎtonml Џlmc1uro ot' 1hu fl'llc.lnndlnl! off•Jllo АMino th,,1 remit In chtt11go to tho 11r\lhhe111urnl ntБlhotio, or 1hВ building or tho lown. O C11lno Ill Est1bll1hm1nt: A holol p1011iding a minimum or !JO, 199 qunlilyln!J i'lco11Jn11 units, A minimum nrott ofl.000 1quu,i fbo1 of quttlifyfn8 indoor public ,puce," CMlno room with H tnlnimuttt nren of ,,ooo s11unfll l\:01 nnJ ba11que1 litcllltlГj that would '"commodn10 n minimum(!( ,oo il"ffi'Jn,. D This form Is being submitted as an application for the retention of a casino license. D The above-named business entity Is an applicant for a statement of compliance. INITIALS DATE: ___ _ __ ITEM 8. FORMER OFFICERS Use Attachment 8 to provide the following information for each person, not listed in response to Item 7, who was an officer of the business entity during the last 10 year period. Officers include all persons serving as president, secretary, treasurer, chairman of the board, vice-president or any such other offices as may be prescribed by the formation documents. NAME ANO LAST KNOWN HOME ADDRESS OFFICE HElO ITEM 9. COMPENSATION OF OFFICERS AND DIRECTORS OATES OFFICE HElO FROM TO PRESENT OCCUPATION ANO BUSINESS ADDRESS DATE OF BIRTH Use Attachment 9 to provide the following information regarding the amount of total annual compensation received during the last calendar year and the amount to be received during the subsequent calendar year by each director, trustee, and officer, of the business entity, whether such compensation is in the form of salary, wages, commissions, fees, securities or other ownership interest, bonuses or otherwise. NAME COMPENSATION LAST CALENDAR YEAR COMPENSATION SUBSEQUENT CALENDAR YEAR FORM OF COMPENSATION ITEM 10. COMPENSATION OVER $100.000 Use Attachment 10 to provide the following information for each person, other than those listed in response to Item 9, who currnntly receives, or who reasonably can be expected to receive within one calendar year from the date of this form, compensation os doscrlbod Ii, lt@m 9 thilt exceeds $100,000 per year. NAME DATE OF BIRTH BUSINESS ADDRESS POSITION ANO LINGTH o, TIMI EMPLOYEO WITH THE BU51NfL ENfftY AMOUNfo; tOMPtNSArlUN INITIALS¯= DATE:°--- ITEM 13. VOTING SHAREHOLDERS Use Attachment 13 to provide the following information for each person or entity holding of record or having a beneficial interest in any voting securities or other ownership interest issued by the business entity. This information must be provided as of a date no more than 60 days prior to the date of this application. (Note: if the business entity submitting this form is an applicant for a casino license, or is a nonpublic holding or intermediary company of such an applicant, then a completed Multi-jurisdictional Personal History Disclosure Form or Business Entity Disclosure Form, as the case may be, must be filed for each person or entity holding or having a beneficial interest in the voting securities or other ownership interest of the business entity. If the business entity submitting this form is a publicly-traded holding company of an applicant for a casino license, then a completed Multi-jurisdictional Personal History Disclosure Form or Business Entity Disclosure Form, as the case may be, must be filed for each person or entity holding or having a beneficial interest in the voting securities or other ownership interest of the business entity unless the Commission has granted a waiver of the qualification requirement as to such persons or entity). NAME ANO HOME ADDRESS DATE OF BIRTH ITEM 14. NON-VOTING SHAREHOLDERS CLASS OF VOTING SECURITIES OR OTHER OWNERSHIP INTEREST HELD NUMBER OF SHARES HELO % OF OUTSTANDING VOTING SECURITIES OR OTHER OWNERSHIP INTEREST HELO Use Attachment 14 to provide the following information for each person or entity holding of record or having a beneficial interest in any nonvoting securities or other ownership interest issued by the business entity. This information must be provided as of a date no more thun 60 days prior to the date of this application. (Note: If the business entity submitting this form is an applicant for a casino license, or Is II nonpublic holding or intermediary company of such an applicant, then a completed Multi-jurisdictional Personal History Disclosure Form or Business Entity Disclosure Form, as the case may be, must be filed for each person or entity holding or having a beneficial Interest In the nonvottns securltlos or other ownership interest of the business entity. If the business entity submitting this form is a publicly.traded holding company of 1n 1ppllc11nt for a casino license, then a completed Multi-jurisdictional Personal History Disclosure Form or Business Entity Disclosure Form, ;is the case m;iy be, must be filed for each person or entity holding or having a beneficial interest in the nonvoting securities or other ownership Interest of tho business entity, unless the Commission has granted a waiver of the qualification requirement as to such persons orentlty). NAME ANO HOME ADDRESS DATE OF BIRTH CLASS OF NONVOTING SECURITIES OR OTHER OWNERSHIP INTEREST HELO NUMBER OF SHARES HELO "OF OUT$TANDINO NONI/Ol1N6 HCU4lllll O5 OTHER OWNERSHIP INfER6STHELO INITIALS DAiE: -- ITEM 15. DESCRIPTION OF LONG TERM DEBT Provide as Attachment 15, a description of the nature, type, terms, covenants, conditions and priorities of all outstanding bonds, loans, mortgages, trust deeds, notes, debentures, or other forms of indebtedness issued or executed (including loans made by shareholders, or to be issued or executed by the business entity, which mature more than one year from the date of issuance or which, by their terms, are renewable for a period of more than one year from the date of issuance (or, in the space below, provide a specific cross-reference to the applicable document(s) filed with this application that contain(s) all of the requested Information. ITEM 16. HOLDERS OF LONG TERM DEBT Use Attachment 16 to provide the following information for each person or entity holding any outstanding bonds, loans, mortgages, trust deeds, notes, debentures, or other forms of indebtedness executed or issued by the business entity, which mature more than one year from the date of issuance or which, by their terms, are renewable for a period of more than one year from the date of issuance. (Note: Some or all of the persons or entities listed below may be required by the Commission to submit a completed Multi-jurisdictional Personal History Disclosure Form or Business Entity Disclosure Form, as the case may be.) NAME AND ADDRESS DATE Of BIRTH TYPE AND CLASS OF DEBT INSTRUMENT HELD ITEM 17. OTHER INDEBTEDNESS AND SECURITY DEVICES DOLLAR AMOUNT OF DEBT HELO (Both Original Amount and Current Balance) Provide as Attachment 17, a description of the nature, type, terms, conditions and covenants of all outstanding loans, mortgages, trust deeds, pledges, lines of credit, or other evidence of indebtedness or security devices utilized by the business entity other than those described In response to Items 15 and 16 (or, in the space below, provide a specific cross-reference to the applicable document(s) flied with this appllciltlon thut contain(s) all of the requested information). ITEM 18. HOLDERS OF OTHER INDEBTEDNESS Use Attachment 18 to provide the following information with respect to each holder of any outstanding loon, mortgage, trust deed, pledse or other evidence of indebtedness or security device described in response to Item 17. (Note: Some or illl of the persons listed In response to this item may be required by the Commission to submit a completed Multi-jurisdictional Personal History Disclosure Form or Business Entity Dlsclosura Form, as the case may be). NAME AND ADDRESS DATE OF BIRTH TYPE OF DEBT INSTRUMENT HELD OOLlAR AMOUNT OF DE8f llUO Uot11 Ori ln1I Amount 1nd Curr,nt B1l1ntt INlflALS -- OAfl:: ---- ITEM 29. BANKRUPTCY OR INSOLVENCV PROCEEDINGS AND APPOINTED RECEM;R. A(jENJ OR lRUSTl!E(Coptlnulldl B. Has any receiver, fiscal agent, trusteo, raorganlzatlon trustee or similar officer, been i!ppolt,ted In the last lO·ye11r period by a court for the business or property of the business entity or Its parent, holding, lntermedl,uy or $Ubsldl,ny companies? 0 Yes O No If yes to any of the above questions, use Att1chm1nt 29C to provide the followln& lnformiltion for Heh procllftdin9: NAME OF PERSON APPOINTED COUl ftlASON fOft Al'POINTMINf ITEM 30. A. During the last 10-year period, has the business entity, Its parent or any subsidiary, ever had any license or ccrtlflcate Issued by a government agency in this state or any other Jurisdiction, denied, suspended or rnvokod? C'J Vfis O No If yes, use Attachment 30A to provide the followlng lnrormatlon for each license or certlflc:Dtll denied, suspGndod or rovok11d: TYPE OF UCENSE OR CERTIFICATE NAME AfiD LOCATION OF GOVERNM!NTALAGENCY ACTION TAKEN DAU ftfMDN rnn ACTION TAKCN e. Has the buslnoss entity, Its parent or any subsidiary, ever applied in any jurisdiction for a licens1.1, pormlt, or other authorization, to p1rtlclpat11 In lawful aambllng operations (including casino gaming, horse racing, dog racins. rml·mutuoi operation, lottery, .sports betting, etc.I? CJ Yes C No If yes, use Attachment 308 lo provldo tho following information for each license, permit or other authorlmtlon applied for: I! IHUII>, OIVC APPROPRIATE N4M! ANO ADIJR¾iS OI' IJCCNSINO AOINCV PATE OF APPLICATION DISPOSITION TYPE OF GAMBLINflAClWITY UCIN51, PIA Mil, OR OTHI¿ SUCH (GRANTED, OENIED, PENDING) NUMHA, ANO THI 1x,111ATION DATI INITIALS __ DATE:---- ITEM 38. REPORTS OF ACCOUNTANTS Provide as Attachment 38, a copy of all reports and correspondence, other than those previously included in this application, submitted in the last five years by independent auditors for the business entity which pertain to the issuance of financial statements, managerial advisory services, or internal control recommendations. Include the name, address and telephone number of the current outside auditor(s). ITEM 39. FORMATION DOCUMENTS Provide as Attachment 39, a certified copy of the Articles of Incorporation, Charter and Bylaws of the corporation, the partnership agreement of the partnership, or formation documents of the business entity, as applicable, with all amendments and proposed amendments to date. Highlight the portions of these documents that comply with the requirements of the Virgin Islands Casino and Resort Control Act of 1995. ITEM 40. ORGANIZATIONAL CHART A. Provide as Attachment 40A, a current ownership organizational chart of the business entity, its parent company and each subsidiary of the business entity. B. Provide as Attachment 408, a functional Table of Organization for the business entity filing this Business Entity Disclosure Form, including position descriptions and the names of persons holding such positions. ITEM 41. TAX RETURNS Provide as Attachment 41, a copy of all 1120 Forms (U.S. Corporate Income Tax Return ), 1065 (Partnership Tax Return Limited Liability Company Return) and 941 Forms (Employer's Quarterly Federal Tax Return) as applicable, submitted to the Internal Revenue Service in the last five years. INITIALS DATE:---- Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select Select INSERT NARRATIVE OR DOCUMENTS(S) HERE ITEM 4. DESCRIPTION OF FORMER BUSINESS INSERT NARRATIVE OR DOCUMENT($} HERE J\ttochmont 4: Paao_of_Pasos INrflALS -- OAn: --- AliACHMEN"f 10 CQMpgNS@QN QYEB $100,000 NAM! OAtto,a1ATH 81JSINUS ADDRESS - POSITION ANO llNQTH or flMC tMPlOYEO AMOUNT OF WlfH THE IIJitNm rnr,rv COMP!NSAflON Attachment 10: PHge_of_Pages INtrlALS OAiE: ---- ITEM 11. BONUS. PROFIT SHARING. PENSION. RETIREMENT. DEFERRED COMPENSATION AND SIMILAR PLANS INSERT NARRATIVE OR DOCUMENT(S) HERE Attilchmcint 11: Pll8C! __ of_P1111os INlrtALS _ DAH: --- ITEM 15. DESCRIPTION OF LONG TERM DEBT INSERT NARRATIVE OR DOCUMENT(S) HERE Attachment 15: Page_or_Pagos INITIALS __ OArE: --- ATTACHMENT 16 HOLDERS PE LONG TERM QEQT NAME ANO ADDRESS 0,UE OF BIRTH TYPE ANO CLAS$ o, OUT 1NffAUMENftiELO DOLLAR AMOUNT Of OUT HUD tooth Or11lntl Amount ond Corrtni Ulinetl Attachment 16: Page_of_Pngl!s INITIALS __ DATE:---- ITEM 17. OTHER INDEBTEDNESS AND SECURITY DEVICES INSERT NARRATIVE OR DOCUMENT($) HERE Attachment 17: Page_or_Pages 1Nll1Al5 tlAl'E: --- AlTACHMENT 18 HQLDERS Of OTHER !NPEQTEQNESS NAM( AND AODRUS 0AfEOF81RTH TYPt OF OUT INSfRUM[NT HILD 001.lAA AMOUNT OF OUT HILO !Both Ori1ln;11 Amoont and Curtont Balanc1) Attachment 18: Page __ of __ Pages INrflAIS __ OAH: ---- ITEM 19A. SECURITIES OPTIONS INSERT NARRATIVE OR DOCUMENT(S) HERE Attachment 19A: Pagc_or_Pages INlflA+S __ DATE: --- ATTACHMENT 20 flNANCjAL INSIIIYIIAN!i NAME AND ADDRm tiPt Of' ACCOVNT(S) AttOUNT NUMUR{SI TIMI PIRIOD ACCOUNT HILD ,ROM TO Attachment 20: Page_of_Pages INlflALS -- OAfl': ---- ATTACHMENT 24 CRIMINAL HISIABY NAMEO,CASE NATURe OF CHAACE OAfl Of CHARGE NAME AND ADDum ov DISPOSITION ANO OOCKtt NUMHA OR COMPLAINT OA COMPLAINT IAW ENFORCEMENT AGENCY (ACQUITT!O, CONVICTtO, SENTtNtE OR COURT INVOlVEO C1SM1SSEO ETC.I Attachment 24: P1g8 __ of_P1gos INITIALS ___ f:JAiE: ---- ITEM 32A. Fl NANCIAL STATEMENTS INSERT NARRATIVE OR DOCUMENT(S) HERE Altachmenl 32A: Poge_ot __ Pages INITIALS OAn: __ _ ITEM 320. FINANCIAL STATEMENTS INSERT NARRATIVE OR DOCUMENT(S) HERE Attachment 320: Page_of_Pages INlllALS OAiE: --- ITEM 33A. ANNUAL REPORTS INSERT NARRATIVE OR DOCUMENT(S) HERE Att11chment 33A: Paga_of __ Posos INITIALS OATE: --- ITEM 338. ANNUAL REPORTS INSERT NARRATIVE OR DOCUMENT(S) HERE l\tt11chm1rnt 33B: P11111_of_P1ges INIT'IALS __ OA1'E: --- ITEM 34. QUARTERLY REPORTS INSERT NARRATIVE OR DOCUMENT(S) HERE Att3chment 34: Page __ of __ P31!CS INITIALS __ DATE: --- ITEM 35. INTERIM REPORTS INSERT NARRATIVE OR DOCUMENT(S) HERE Attachment 35: P11ge_of_Pases INltlAl OA1E: --- ITEM 36. PROXY AND INFORMATION STATEMENT INSERT NARRATIVE OR DOCUMENT(S) HERE Attachment 36: Pog9_or_P11flOS INl1'1ALS __ 0Aft: --- ITEM 37. REGISTRATION STATEMENT INSERT NARRATIVE OR DOCUMENT(S} HERE Attachment 37: Page __ of __ Paaes INITIALS __ DATE: --- ITEM 38. REPORTS OF ACCOUNTANTS INSERT NARRATIVE OR DOCUMENT(S) HERE Att1chmont 38: P1se_of_Pages INrtlALS __ OArt: --- ITEM 39. FORMATION DOCUMENTS INSERT NARRATIVE OR DOCUMENT(S) HERE Attnchmont 30: Pogo __ of __ Pagos INltlALS __ OATE: --- ITEM 40A. ORGANIZATIONAL CHART INSERT NARRATIVE OR DOCUMENT(S) HERE Attachment 40A: Po11e_of_Pagos 1Nlf1Al5 _ DArE: __ _ ITEM 408. ORGANIZATIONAL CHART INSERT NARRATIVE OR DOCUMENT(S) HERE Attochmont 409: Pa811_of_Pogus INITIALS -- DATE: --- ITEM 41. TAX RETURNS INSERT NARRATIVE OR DOCUMENT(S) HERE Attochm11nt 41: P11ge_or_P11gas INlflAL.S __ DATE: ---