License Application Horse Racing {ENF-84}

NEVADA STATE GAMING CONTROL BOARD LICENSE APPLICATION (HORSE RACING) PLEASE PRINT IN INK OR TYPE APPLICATION DATE: FOR OFFICIAL USE ONLY LICENSE APPLIED FOR: LICENSE NO.: DATE OF ISSUE: APPLICANT'S NAME (LAST, FIRST, MIDDLE): SOCIAL SECURITY NO.: LICENSE FEE: $ FEE PAID BY: SEX: HEIGHT: WEIGHT: EYE COLOR: HAIR COLOR: DATE OF BIRTH (MONTH/DAY/YEAR): RECEIPT NO.: CASH CHECK CHECK/ M.O. NO.: M.O. MAILING ADDRESS: IT IS STIPULATED AND AGREED THAT ANY NOTICE, CORRESPONDENCE OR PAPERS OF ANY NATURE ADDRESSED TO ME FROM THE STATE GAMING CONTROL BOARD IS TO BE SENT TO THE FOLLOWING MAILING ADDRESS: STREET ADDRESS/P.O. BOX/APT. NO. CITY STATE ZIP HOME PHONE NO.: BUSINESS NO.: CELL PHONE NO.: THE FOLLOWING INFORMATION IS REQUIRED FOR ALL LICENSE CATEGORIES. IF ANY ANSWER IS "YES," EXPLAIN BELOW: 1. Have you EVER been ARRESTED, CHARGED, or CONVICTED of any violation involving ILLEGAL GAMBLING or BOOKMAKING? ....................................................................................................................................... Yes No 2. Have you been ARRESTED, CONVICTED, or CHARGES DISMISSED AFTER ARREST for any criminal offense in the past TEN (10) years? ......................................................................................................................... Yes No 3. Have you been CHARGED for any crime, offense or violation in which action (warrant, summons, indictment, complaint) is still pending? ....................................................................................................................... Yes No DATE CITY STATE OFFENSE (NATURE OF CHARGE) DISPOSITION 4. Have you been FINED, SUSPENDED, REVOKED, or DENIED a racing license by ANY racing commission or Board of Stewards at a race track?..................................................................................................................... Yes No 5. Have you ever been EXPELLED, EJECTED, or DENIED privileges at any race track? ......................... Yes No NATURE OF DATE LOCATION SUSPENSION FINE RESTORED? VIOLATION 6. Have you ever used an ALIAS or ASSUMED name or have you ever been known by another name? .. Yes 7. Do you have a State of Nevada Business License with the Secretary of State? ..................................... Yes License # License # No No (USE ADDITIONAL BLANK SHEETS IF NECESSARY) ARE YOU A U.S. CITIZEN? Yes No PLACE OF BIRTH IF "NO," PROVIDE (1) ALIEN REGISTRATION NO.: OR (2) DOCUMENTATION OF ELIGIBILITY TO BE EMPLOYED IN THE UNITED STATES EXPIRES: IN CASE OF EMERGENCY CONTACT: NAME ADDRESS PHONE NO. ~COMPLETE APPLICABLE SECTIONS OF PAGE 2 AND SIGN COMPLETED APPLICATION~ ENF-84 (6/14) American LegalNet, Inc. www.FormsWorkFlow.com LICENSE APPLICATION (HORSE RACING) THE FOLLOWING INFORMATION IS REQUIRED FOR ALL OWNERS: NEVADA LICENSED TRAINER: NAME ADDRESS No PHONE NO. PAGE 2 DO YOU RACE UNDER A STABLE/CORPORATION NAME IN NEVADA? Yes IF "YES," INDICATE STABLE/CORPORATION NAME: LIST NAMES OF HORSES YOU PLAN TO RACE IN NEVADA: NAME OF OTHER OWNERS NAME OF ANIMAL(S) OR ANYONE HAVING AN INTEREST WITH YOU IN NAMED ANIMAL ADDRESS INTEREST OR % OWNED THE FOLLOWING INFORMATION IS REQUIRED FOR ALL TRAINERS: LIST OWNERS FOR WHOM YOU ARE NOW TRAINING: NAME OF OWNER (LAST, FIRST, MIDDLE INITIAL) ADDRESS PLEASE READ CAREFULLY BEFORE SIGNING: I hereby make application for license to be issued in accordance with the terms and provisions of the Rules and Regulations of the State Gaming Control Board and Nevada Gaming Commission. The undersigned says that he/she is the applicant above named; that he/she has read the complete application and knows the contents thereof, that the same is true of the application's own knowledge, and is made for the purpose of inducting the State Gaming Control Board to issue the license applied for, that he/she agrees as a condition precedent to receiving said license that he/she will strictly comply with the laws of the State of Nevada and with the Rules and Regulations of the State Gaming Control Board and Nevada Gaming Commission. I understand that notification to the State Gaming Control Board of change of address is the sole responsibility of the licensee. I hereby consent to a search of my person, vehicles, tack rooms, stable area rooms, or stalls by representatives of the State Gaming Control Board while on grounds under the supervision of the State Gaming Control Board and Nevada Gaming Commission. I CERTIFY THAT THE STATEMENTS AND ANSWERS I HAVE MADE IN THIS APPLICATION ARE TRUE AND CORRECT. SIGNATURE OF APPLICANT FOR LICENSE APPLICANT'S UNDER THE AGE OF 18 VERIFICATION OF DATE OF BIRTH HAS BEEN VERIFIED BY: SOURCE DOCUMENT SIGNATURE OF PARENT/GUARDIAN American LegalNet, Inc. www.FormsWorkFlow.com ENF-84 (6/14)