Legal Gaming Licence Eligibility Form

LEGAL GAMING LICENCE ELIGIBILITY FORM

This Legal Gaming Licence Eligibility Form is entered into as of Date: between Applicant Name: with Business Address: and Licensing Authority: with Address: .

Recitals

WHEREAS, the Applicant seeks authorization to obtain a gaming licence and must declare eligibility, disclosures and attestations regarding character, financial responsibility and regulatory compliance; and

WHEREAS, the Licensing Authority administers licensing standards and requires a completed eligibility form, supporting documentation and truthful certification as a condition precedent to consideration of any licence application; and

WHEREAS, the parties desire to record the Applicant's representations and acknowledgements in connection with the Applicant's submission for licensing review.

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

1. Eligibility Criteria

1.1 Applicant represents and warrants that Applicant is at least 21 years of age and is not subject to any statutory disqualification from holding a gaming licence. Date of birth:

1.2 Entity Type (select all that apply):
Individual   Corporation   Limited Liability Company (LLC)   Partnership   Other (specify):

2. Disclosure and Background

2.1 Provide the full legal name of the individual who will serve as principal officer or controlling person:

2.2 Has Applicant, any principal, or any entity under common control been convicted of, or pled nolo contendere or guilty to, a felony or any crime involving dishonesty, fraud, gambling offences, or regulatory violations within the past 10 years? Yes No

3. Financial Responsibility

3.1 Applicant affirms that Applicant or Applicant's controlling entities possess sufficient financial resources to operate in compliance with applicable laws and to meet all escrow, bond and tax obligations. Applicant must disclose material bankruptcy filings within the last 10 years. Has Applicant or any principal filed for bankruptcy within the last 10 years? Yes No

4. Compliance and Operational History

4.1 Has Applicant or any principal ever had a gaming licence denied, suspended or revoked by any regulatory body? Yes No

4.2 Has Applicant or any principal been subject to a civil enforcement action, administrative penalty, or other regulatory sanction related to gaming, money laundering, fraud, or similar matters? Yes No

5. Required Supporting Documentation

Applicant certifies that the following documents are submitted with this form (check each applicable box). Failure to provide required documents may result in denial or delay.

Articles of Incorporation / Organization and bylaws/operating agreement
Audited or reviewed financial statements for the last two fiscal years
Background check consent forms for all principals
Business plan and internal controls documentation
Other (describe below)

6. Applicant Certification and Attestation

6.1 By signing below, Applicant certifies under penalty of perjury that the information provided in this form and the accompanying documentation is true, complete and correct to the best of Applicant's knowledge. Applicant acknowledges that false statements, omissions or misrepresentations may constitute grounds for denial, suspension or revocation of a licence and may give rise to civil or criminal penalties.

6.2 Applicant agrees to submit to background investigations, to provide fingerprints and to cooperate with investigations conducted by the Licensing Authority or its authorized agents. Applicant consents to release of information by financial institutions, law enforcement and regulatory agencies as necessary to verify representations made herein.

7. Notices

All notices, requests and other communications required or permitted under this Form shall be in writing and shall be delivered to the mailing addresses set forth in the opening paragraph or to such other address as either party may designate in writing. Notice shall be deemed given upon personal delivery, upon confirmed facsimile transmission, or three days after deposit in the mail, postage prepaid, return receipt requested.

8. Amendments, Waiver and Counterparts

No amendment to this Form shall be effective unless in writing and signed by both parties. No waiver by either party of any breach or default shall be deemed a waiver of any subsequent breach or default. This Form may be executed in counterparts, each of which shall be deemed an original, and all of which together shall constitute one instrument.

9. Governing Law; Entire Agreement; Severability

This Form shall be governed by and construed in accordance with the laws of the jurisdiction in which the Licensing Authority sits, without regard to conflicts of law principles. This Form constitutes the entire agreement between the parties regarding the subject matter hereof and supersedes all prior agreements and understandings, whether written or oral. If any provision of this Form is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

10. Certifications and Acknowledgements

The undersigned certifies that he or she is duly authorized to execute this Form on behalf of the Applicant and that the statements contained herein are made with full knowledge that the Licensing Authority will rely upon them in determining eligibility for a gaming licence.

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