Gaming License Application Form

GAMING LICENSE APPLICATION FORM

Applicant Name:    Entity Type: Corporation LLC Partnership Sole Proprietorship Other

Business Registration / Tax ID Number:    Date of Application:

RECITALS

WHEREAS, Applicant seeks a license authorizing the conduct of regulated gaming activities as described in this application and in accordance with applicable statutory and regulatory requirements; and

WHEREAS, Licensing Authority is the governmental body empowered to review, grant, condition, suspend, or revoke gaming licenses and to impose terms necessary to protect the public interest and ensure gaming integrity; and

WHEREAS, Applicant submits the following disclosures, attestations, and supporting documentation to permit Licensing Authority to evaluate Applicant's suitability for licensure;

NOW THEREFORE, in consideration of the mutual covenants contained herein and other good and valuable consideration, the parties agree as follows:

1. LICENSE REQUEST AND SCOPE

1.1 Application. Applicant applies for a gaming license authorizing the activities selected below. The grant of a license is conditioned upon the truthfulness of this application, verification of submitted materials, payment of required fees, and such background checks and investigations as Licensing Authority requires.

1.2 License Type Requested: Casino (on-premises) Interactive/Online Gaming Sports Wagering Manufacturer / Supplier Other

1.3 Proposed Term: years. License, if issued, shall be subject to renewal and such conditions as set by Licensing Authority.

2. BACKGROUND DISCLOSURES

2.1 Criminal and Regulatory History. Applicant must disclose any felony conviction, any conviction related to fraud, gaming, or financial misconduct, and any prior disciplinary actions by a gaming regulator.

Have any principals been convicted of a disqualifying offense? Yes No

3. FINANCIAL DISCLOSURE

3.1 Financial Condition. Applicant shall submit audited financial statements for the most recent two fiscal years, a current balance sheet, and a certification of adequate working capital to sustain operations for the initial licensing period.

3.2 Surety / Bond Amount (if required): $

4. COMPLIANCE, RECORDS, AND REPORTING

4.1 Applicant acknowledges and agrees that, as a condition of licensure, Applicant must maintain complete and accurate books and records, implement anti-money laundering controls, provide periodic reports to Licensing Authority, and cooperate with investigations. Failure to comply may result in fines, suspension, or revocation.

5. INSPECTION AND AUDIT CONSENT

Applicant consents to periodic inspections, audits, and reviews of facilities, systems, and records by Licensing Authority or its authorized agents. Applicant shall permit immediate access upon reasonable notice or when exigent circumstances exist.

6. RENEWAL, SUSPENSION, AND REVOCATION

The license issued pursuant to this application may be renewed upon timely submission of renewal materials and payment of fees. Licensing Authority may suspend or revoke a license for material misrepresentation, criminal activity, failure to comply with statutes or regulations, or conduct that threatens the public interest or the integrity of gaming operations.

7. FEES AND PAYMENT

Applicant submits the non-refundable application fee and acknowledges that additional fees may be required for investigation, processing, and annual licensing. Failure to pay required fees may result in denial or suspension.

Application Fee: $    Investigation Fee: $

8. NOTICES

All notices required or permitted under this application shall be in writing and delivered to the addresses below.

9. AMENDMENTS, WAIVER, GOVERNING LAW

9.1 Amendment and Waiver. No amendment, modification, or waiver of any provision of this application shall be effective unless in writing signed by the party against whom enforcement is sought. No failure or delay in exercising any right shall operate as a waiver.

9.2 Governing Law. This application, and any license issued pursuant to it, shall be governed by and construed in accordance with the laws of the jurisdiction in which Licensing Authority is vested, without regard to conflict of laws principles.

10. ENTIRE AGREEMENT; SEVERABILITY

This application, together with any attachments, exhibits, and supporting documentation submitted herewith, constitutes the entire statement of the Applicant's request for licensure and supersedes all prior representations and agreements, whether written or oral. If any provision of this application is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

CERTIFICATION AND AUTHORIZATION

By signing below, Applicant certifies under penalty of perjury that all information provided in this application and in any accompanying documents is true, complete, and correct to the best of Applicant's knowledge. Applicant authorizes Licensing Authority to conduct background checks, financial investigations, and any other inquiries necessary to determine Applicant's suitability for licensure, including obtaining criminal history records where permitted by law.

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