CASINO SERVICING INDUSTRY NON-GAMING RELATED LICENSE EXEMPTION FORM > Jab SA ees ieee = te UNITED STATES VIRGIN ISLANDS CCC:NGRLE.2 REV.1/2016 CASINO SERVICING INDUSTRY NON-GAMING RELATED LICENSE EXEMPTION NOTE: A. THE COMMISSION MAY EXEMPT ANY PERSON OR FIELD OF COMMERCE FROM THE LICENSING REQUIREMENTS IF IT DEMONSTRATES THAT IT IS REGULATED BY A PUBLIC AGENCY OR THAT IT WILL PROVIDE GOODS OR SERVICES IN INSIGNIFICANT AMOUNTS OR QUANTITIES AND THAT LICENSING IS NOT NECESSARY IN ORDER TO PROTECT THE PUBLIC INTEREST OR ACCOMPLISH THE POLICIES OF THE ACT. IN DETERMINING WHETHER TO GRANT AN EXEMPTION, THE FOLLOWING FACTORS WILL ALSO BE CONSIDERED: 1. NUMBER OF TRANSACTIONS 2. FREQUENCY OF TRANSACTIONS 3. DOLLAR AMOUNTS OF TRANSACTIONS: THE TOTAL DOLLAR AMOUNT OF SUCH TRANSACTIONS WITH ONE OR MORE CASINO LICENSEE OR APPLICANT IS OR WILL BE LESS THAN $50,000 WITHIN ONE 12-MONTH PERIOD; OR NOT OVER $120,000 WITHIN THREE CONSECUTIVE 12-MONTH PERIODS. NATURE OF GOODS OR SERVICES PROVIDED OR BUSINESS TRANSACTED. MAXIMUM POTENTIAL PERIOD OF TIME NECESSARY TO FULLY PROVIDE THE GOODS, PERFORM THE SERVICES, OR COMPLETE THE BUSINESS TRANSACTION. EXEMPTION FROM LICENSING REQUIREMENTS BY THE CASINO CONTROL COMMISSION IS STRICTLY DISCRETIONARY. INSTRUCTIONS THIS APPLICATION SHALL BE COMPLETED BY ANY ENTITY DOING NON-GAMING RELATED BUSINESS WITH CASINO LICENSEES OR CASINO APPLICANTS WHO WISHES TO OBTAIN AN EXEMPTION FROM THE LICENSING REQUIREMENTS. INFORMATION REQUESTS MUST BE ANSWERED COMPLETELY BY THE APPLICANT. ALL ENTRIES ON THIS FORM, EXCEPT SIGNATURES, MUST BE TYPED OR BLOCK PRINTED IN BLACK INK. IF YOUR APPLICATION IS NOT LEGIBLE, IT WILL NOT BE ACCEPTED. FOR PURPOSES OF THIS APPLICATION, “ENTERPRISE” OR “ENTITY” SHALL BE DEFINED TO INCLUDE ANY CORPORATION, ASSOCIATION, OPERATION, FIRM, PARTNERSHIP, TRUST, OR OTHER FORM OF BUSINESS ASSOCIATION, AS WELL AS A NATURAL PERSON. SUBMIT AN ORIGINAL OF THIS ENTIRE APPLICATION FORM TO THE U.S. VIRGIN ISLANDS CASINO CONTROL COMMISSION ALONG WITH A FILING FEE OF $100.00. IF THE COMMISSION DETERMINES THAT AN APPLICANT IS INELIGIBLE FOR AN EXEMPTION, THIS FEE WILL BE APPLIED TOWARDS THE NON-GAMING RELATED CASINO SERVICE ENTITY LICENSING FEE. IT IS RECOMMENDED THAT YOU KEEP A COPY OF YOUR COMPLETED APPLICATION FOR YOUR RECORDS. AN AUTHORIZED ENTITY MUST SIGN THE ACCOMPANYING VERIFYING AFFIDAVIT BEFORE A NOTARY PUBLIC. For VICCC use only VIRGIN ISLANDS CASINO CONTROL COMMISSION NAME OF ENTERPRISE (NOTE: STATE THE NAME AS IT APPEARS ON THE CERTIFICATE OF INCORPORATION, CHARTER, ETC.) D/BIA OR TRADE NAME: CONTACT PERSON: NAME TELEPHONE TITLE FAX PRINCIPAL BUSINESS ADDRESS PRINCIPAL MAILING ADDRESS BUSINESS PHONE: (___) EMAIL: **ATTACH AS “EXHIBIT 5A”TO THIS APPLICATION FORM, CURRENT BUSINESS LICENSE (OR AN APPLICATION FOR A BUSINESS LICENSE WITH RECEIPT EVIDENCING PAYMENT) ISSUED BY THE U.S. VIRGIN ISLANDS DEPARTMENT OF LICENSING AND CONSUMER AFFAIRS. CHECK THE APPROPRIATE BOX TO DESCRIBE YOUR BUSINESS FORM. O CORPORATION OPARTNERSHIP OTRUST OJOINT VENTURE (OSOLE PROPRIETORSHIP O LIMITED LIABILITY COMPANY 0 OTHER PLEASE STATE THE TYPE OF GOODS OR SERVICES BEING PROVIDED TO THE CASINO INDUSTRY. **IF THE ENTITY HAS ENTERED INTO ANY WRITTEN AGREEMENTS WITH A CASINO HOTEL, ATTACH AS “EXHIBIT 5B” A COPY OF EACH SUCH AGREEMENT. IF THE ENTITY HAS ENTERED INTO ANY UNWRITTEN AGREEMENTS OR PURCHASE ORDER BUSINESS WITH A CASINO HOTEL, DESCRIBE BELOW THE TERMS OF EACH UNWRITTEN AGREEMENT, INCLUDING IN SAID DESCRIPTION THE EXPECTED DURATION AND TERMS OF COMPENSATION OF EACH SUCH AGREEMENT. IS ENTITY SUBJECT TO REGULATION BY A PUBLIC AGENCY IN THIS TERRITORY OR IN ANY OTHER JURISDICTION? YES NO IF YES, IDENTIFY THE PUBLIC AGENCY AND ITS LOCATION AND DESCRIBE THE NATURE AND EXTENT OF THE REGULATION AS IT AFFECTS THIS ENTITY (FOR EXAMPLE CONTROL OF RATES, INDIVIDUAL QUALIFICATIONS, CRIMINAL RECORDS, ETC.) IS THE DOLLAR AMOUNT OF THE ENTITY’S TRANSACTION WITH THE CASINO LICENSEE PROJECTED TO BE LESS THAN $50,000 WITHIN ONE 12-MONTH PERIOD OR LESS THAN $120,000 WITHIN THREE CONSECUTIVE 12-MONTH PERIODS. YES NO DOES THE ENTITY DO BUSINESS IN ANOTHER GAMING JURISDICTION? YES NO IF YES, WHERE AND WHAT TYPE? HAS THE ENTITY BEEN INDICTED, CHARGED WITH OR CONVICTED OF A CRIMINAL OFFENSE OR BEEN A PARTY TO OR NAMED AS AN UNINDICTED CO-CONSPIRATOR IN ANY CRIMINAL PROCEEDINGS IN THIS TERRITORY OR ANY OTHER JURISDICTION? NO YES; If yes, complete the following: NATURE OF CASE NAME AND ADDRESS OF RESULT OF CASE DATE OF CONVICTION COURT OR AGENCY VERIFYING AFFIDAVIT TERRITORY OF THE UNITED STATES VIRGIN ISLANDS ) DISTRICT OF ST. CROIX ) SS: | SWEAR (OR AFFIRM) THAT THE FOREGOING STATEMENTS ARE TRUE, CORRECT, COMPLETE AND CURRENT AND THAT THIS STATEMENT IS EXECUTED WITH THE KNOWLEDGE THAT ANY MATERIAL MISREPRESENTATION OR WILLFULLY FALSE STATEMENTS MAY SUBJECT ME TO SANCTIONS OR PUNISHMENT. SUBSCRIBED AND SWORN TO BEFORE ME (NAME OF APPLICANT ENTITY) THIS DAY OF NOTARY PUBLIC (SIGNATURE) COMMISSION EXPIRATION DATE (PRINT) SEAL (TITLE) CASINO SERVICING INDUSTRY NON-GAMING RELATED LICENSE EXEMPTION FORM APPLICATION CONDITIONS BY THE SIGNING OF THIS APPLICATION, THE APPLICANT ACKNOWLEDGES THAT IF AN EXEMPTION CERTIFICATE IS ISSUED, IT WILL BECOME THE DUTY OF THE APPLICANT TO ABIDE BY AND COMPLY WITH ALL FEDERAL, STATE AND TERRITORIAL LAWS AS WELL AS THE RULES AND REGULATIONS PROMULGATED BY THE U.S. VIRGIN ISLANDS CASINO CONTROL COMMISSION AND THE DIVISION OF GAMING ENFORCEMENT, DEPARTMENT OF JUSTICE. THE APPLICANT UNDERSTANDS THAT EACH EXEMPTION IS GRANTED ON CONDITION THAT THE ENTITY COMPLIES WITH SECTIONS 506 AND 507 OF THE VIRGIN ISLANDS CASINO AND RESORT CONTROL ACT (EQUAL OPPORTUNITY PROVISIONS). THE APPLICANT AGREES TO COMPLETE A CASINO SERVICING INDUSTRY NON GAMING RELATED LICENSE APPLICATION IF REQUIRED BY THE COMMISSION OR WHENEVER THE DOLLAR AMOUNT OF EACH TRANSACTION WITH ONE OR MORE CASINO LICENSEE OR CASINO APPLICANT EXCEEDS $50,000 WITHIN ONE 12-MONTH PERIOD OR OVER $120,000 WITHIN THREE 12-MONTH PERIODS. THE APPLICANT FURTHER AGREES THAT ANY CERTIFICATE OR EXEMPTION, WHICH MAY HEREAFTER BE GRANTED IS PREDICATED UPON THE STATEMENTS AND ANSWERS HEREIN CONTAINED, WHICH MAY BE SUBJECT TO VERIFICATION BY THE COMMISSION AND THE DIVISION OF GAMING ENFORCEMENT AND THAT FOR ANY MATERIAL OMISSION, FALSE OR MISLEADING STATEMENT OR ANSWER THIS CERTIFICATE MAY BE REVOKED OR APPLICANT MAY BE SUBJECTED TO OTHER SANCTIONS. BY (NAME OF APPLICANT ENTITY) (SIGNATURE) (TITLE) (PRINT) RELEASE OF ALL CLAIMS THE UNDERSIGNED HAS FILED WITH THE U.S. VIRGIN ISLANDS CASINO CONTROL COMMISSION AN APPLICATION FOR AN EXEMPTION FROM THE LICENSING REQUIREMENTS OF THE VIRGIN ISLANDS CASINO AND RESORT CONTROL ACT. THE UNDERSIGNED DOES FOR MYSELF, MY HEIRS, EXECUTORS, ADMINISTRATORS, SUCCESSORS AND ASSIGNS, HEREBY RELEASE, REMISE AND FOREVER DISCHARGE THE GOVERNMENT OF THE U.S. VIRGIN ISLANDS, ITS INSTRUMENTALITIES AND AGENTS INCLUDING THE U.S. VIRGIN ISLANDS CASINO CONTROL COMMISSION, ITS MEMBERS, AGENTS, AND EMPLOYEES, FROM ANY AND ALL MANNER OF ACTIONS, CAUSES OF ACTIONS, SUITS, DEBTS, JUDGMENTS, EXECUTIONS, CLAIMS AND DEMANDS WHATSOEVER, KNOWN OR UNKNOWN, IN LAW OR EQUITY WHICH THE UNDERSIGNED EVER HAD, NOW HAS, MAY HAVE, OR CLAIM TO HAVE, AGAINST ANY OR ALL OF SAID ENTITIES OR INDIVIDUALS ARISING OUT OF OR BY REASON OF THE PROCESSING OF THIS EXEMPTION FROM THE LICENSING REQUIREMENTS OR THE INVESTIGATIONS OR HEARINGS OR OTHER ACTION RELATING TO THE UNDERSIGNED’S APPLICATION FOR EXEMPTION FROM LICENSURE. ], THE UNDERSIGNED, HAVING READ THIS RELEASE, EXECUTE IT VOLUNTARILY WITH FULL KNOWLEDGE OF ITS SIGNIFICANCE. SIGNATURE SUBSCRIBED AND SWORN BEFORE ME THIS DAY OF NOTARY PUBLIC COMMISSION EXPIRATION DATE