Personal History Record (New Registration Only) {4R}

Form 3, APPLICATION FOR REGISTRATION BY HOLDING COMPANY/INTERMEDIARY COMPANY, The applicant agrees, if required:%0D%0Aa. To provide any further financial data or other information which the Licensing Agency may deem necessary or appropriate.%0D%0Ab. To submit herewith balance sheets and profit and loss statements certified by independent certified public accounts, for not more than the 3 preceding fiscal years, or, if the entity has not been in existence more than 3 years, such balance sheets and profit and loss statements from the time of its establishment.%0D%0Ac. To provide to the Licensing Agency an annual profit and loss statement and balance sheet, and a copy of its annual Federal Income Tax return within 30 days after such return is filed with the Federal Government.%0D%0Ad. To provide to the Licensing Agency, at least annually, a complete list of all stockholders, partners, or members after this registration is approved, and in all cases within 30 days after the annual meeting of owners showing the interest held by each. If the applicant’s transfer agent, in the normal course of business, prepares quarterly reports, the applicant shall provide such shareholder list quarterly.%0D%0Ae. To file with the Licensing Agency a report containing a list of all registered equity security holders as of each record date fixed by the applicant for the determination of equity security holders entitled to vote, to receive dividends or other distributions, or to participate in any other corporate action.%0D%0Af. To provide the names of all members, partners, directors, officers, and key executives within 30 days of their election or appointment.%0D%0Ag. To furnish to the Licensing Agency a copy of any document filed with the Securities and Exchange Commission or with any national or regional securities exchange, to be confidential in nature, or furnished by it to any of its equity security holders of any class.%0D%0Ah. That before it:%0D%0Ai. Transfers any security (other than a security issued by it) to any other person;%0D%0Aii. Sells, assigns, transfers, pledges, or makes other disposition of any new issue of security or any issue not previously approved by the Licensing Agency; or%0D%0Aiii. Borrows money to be used, either directly or indirectly, in the gaming operation, except short-term borrowing or loans secured from national banking institutions, or banking institutions chartered in the State of Nevada which shall be reported to the Licensing Agency it shall file a report of its proposed action with the Licensing Agency.%0D%0AIf the Licensing Agency denies the request set forth above, the applicant shall not perform any of those acts so denied.%0D%0Ai. In the event it is required by Federal law to file any report or form with the Securities and Exchange Commission, it shall furnish to the Licensing Agency copies of all such reports and forms furnished to the Securities and Exchange Commission within 30 days after submission of such forms to the Securities and Exchange Commission.%0D%0A%0D%0Awww.FormsWorkflow.com%0D%0A%0D%0A