Name of Individual / Entity Holding Interest:

Business Address:

(To enter another row in below table, press tab key.)

Entity (Licensee or Applicant) in which Interest is held	% of Interest held	Publicly Traded	Privately Held

A holder of any direct or indirect legal or beneficial publicly traded interest of five percent (5%) or more, or privately held interest of one percent (1%) or more, in a Missouri gaming licensee or applicant, is required to obtain a key person or key person business entity license from the Missouri Gaming Commission.

A holder may, however, be exempted from the licensure requirements if such interest is held for passive investment purposes only. Individuals or entities holding up to twenty percent (20%) interest in a licensee or applicant may be exempted by the Commission for one or multiple licenses or applicants. Exemptions shall be for a period of two (2) years unless renewed. Ownership of 20% or more in a licensee or applicant requires licensure by the Commission.

Waiver applications shall be submitted to the Missouri Gaming Commission’s Jefferson City office, P.O. Box 1847, Jefferson City, Missouri 65102 or emailed to mgcmail@mgc.dps.mo.gov.

REQUEST OF WAIVER – The individual or entity named above, as holder of such interest hereby applies in writing certifying under oath as follows:

The acquired interest is for passive investment purposes only;

Holder does not and will not have any involvement in the management activities of the entity in which interest is acquired;

Holder has no intention of controlling the entity in which interest is acquired, regardless of additional stock that may be acquired;

The holder will within ten (10) days notify the Commission of any purchase of stock in the entity which causes the total holding of the entity’s outstanding stock to exceed 20%;

That in the event an intention of controlling or participating in the management of the entity in which interest is acquired or held subsequently develops, holder shall notify the Commission of said change and refrain from participating in management or exercising such control until approved for licensure by the Commission.

If the applicant for waiver is an individual, then the home and business address, occupation, employer, and title shall be provided.

Home Address:

Business Address:

Occupation:

Employer:

Title:

If the applicant for a waiver is a business entity, then it shall provide the following:

Type of entity (corporation, partnership, limited partnership, LLC, LLP, etc.):

State of charter

The names and addresses (both home and business) must be included for the following officers;
(I) chief executive officer; (II) chief financial officer; (III) chief operating officer;
(IV) managing partner; (V) general partners; (VI) members of the board of directors; and
(VII) the registered agent.

**Check all that apply** (Use page 3 for information on additional officers)

Name and title:

PERSON TO BE CONTACTED IN REFERENCE TO THIS WAIVER REQUEST

Name	Title
E-Mail Address	Telephone Number	Fax Number

This page is used to include additional information.

Name and title:
Home address:
Business address:

Name and title:
Home address:
Business address:

Name and title:
Home address:
Business address:

Name and title:
Home address:
Business address:

I, the undersigned, in my capacity as	with

attest that the foregoing information is accurate, and that nothing in the granting of this waiver shall prohibit the Commission, at a future date, in its sole discretion, with or without cause, from requiring any owner of any interest in a license from becoming licensed by the Commission or to divest itself of stock ownership.

Signed: Date:

Notary: Date:

Affix seal: