FINANCIAL AUDIT SERVICES _part6 ppt

55 This is trial version www.adultpdf.com 56 This is trial version www.adultpdf.com 57 This is trial version www.adultpdf.com 58 This is trial version www.adultpdf.com 59 This is trial version www.adultpdf.com 60 This is trial version www.adultpdf.com 61 BUSINESS DISCLOSURE FORM GENERAL INSTRUCTIONS TYPE OR PRINT LEGIBLY AN ANSWER TO EVERY QUESTION. IF A QUESTION DOES NOT APPLY, SO STATE WITH “N/A”. IF SPACE IS INSUFFICIENT, CONTINUE ON A SEPARATE PAGE AND PRECEDE EACH ANSWER WITH THE APPROPRIATE SECTION NUMBER AND TITLE. DO NOT MISSTATE OR OMIT ANY MATERIAL FACT(S) AS INFORMATION PROVIDED IS SUBJECT TO VERIFICATION. THE AUTHORIZED COMPANY REPRESENTATIVE RESPONSIBLE FOR COMPLETING THE FORM MUST INITIAL EACH PAGE, INCLUDING ATTACHED SHEETS. BY INITIALING EACH PAGE, THE COMPANY REPRESENTATIVE IS ATTESTING TO THE ACCURACY AND COMPLETENESS OF THE INFORMATION CONTAINED ON THAT PAGE. THE COMPLETION OF THIS BUSINESS DISCLOSURE FORM IS A REQUIREMENT OF THE SCIENTIFIC GAMES CORPORATION (“SGC”) COMPLIANCE PROGRAM. MISREPRESENTATION OR FAILURE TO PROVIDE THE INFORMATION REQUESTED MAY BE CONSIDERED SUFFICIENT CAUSE FOR THE REFUSAL TO ENTER INTO OR REVOCATION OF AN AGREEMENT WITH SGC OR ANY OF ITS SUBSIDIARY COMPANIES. ADDITIONALLY, YOU ARE ADVISED THAT ANY FACT NOT DISCLOSED HEREIN THAT WOULD HAVE CAUSED SCIENTIFIC GAMES NOT TO ENTER INTO AGREEMENT WITH YOU IS SUFFICIENT CAUSE FOR THE IMMEDIATE TERMINATION OF ANY SUCH AGREEMENT AND ENTITLES SCIENTIFIC GAMES TO ANY DAMAGES CAUSED BY FAILURE TO DISCLOSE THIS FACT. YOU ARE REQUIRED TO DISCLOSE IMMEDIATELY TO SCIENTIFIC GAMES ANY CHANGE IN THE INFORMATION REPORTED ON THIS FORM THAT OCCURS SUBSEQUENT TO THE COMPLETION OF THIS FORM. IT IS UNDERSTOOD THAT ANY SUCH CHANGE IN INFORMATION WILL BE EVALUATED BY SCIENTIFIC GAMES AND THAT SCIENTIFIC GAMES MAY CHOOSE AT ITS DISCRETION TO TERMINATE ANY AGREEMENT WITH YOU AS A RESULT OF THIS INFORMATION. FOR PURPOSES OF THIS DISCLOSURE FORM, SGC REFERS TO ANY OF ITS SUBSIDIARY OR AFFILIATE COMPANIES, INCLUDING BUT NOT LIMITED TO, SCIENTIFIC GAMES INTERNATIONAL, INC., AND MDI ENTERTAINMENT, LLC. 1. GENERAL BUSINESS INFORMATION DATE: _____________ Name of Business: ___________________ Business Address: ___________________ Street City __________________________ State Country Zip Code Business Telephone: Fax: ______________ (Include Area Code or Country Code) E-mail Address: _______ Web site: __________ This is trial version www.adultpdf.com 62 Trade name to be used: _________________________ Other name(s) by which the company has been known: ____________ ___________________________________ Federal Tax ID Number (if applicable): ___________________ Describe the principal nature of the company’s business: _________ ________________________________ _______________________________ List all states and jurisdictions in which business is conducted: ______ ________________________________ ________________________________ 2. RELATIONSHIP WITH SCIENTIFIC GAMES CORPORATION (“SGC”): A. Briefly describe your company’s current or proposed business relationship with SGC: __________________________________ __________________________________ __________________________________ B. Does your company have a signed contract or any type of agreement with SGC? YES _____ NO ______ C. Name of the person(s) with SGC that serve(s) as your company’s primary contact. D. Name of the person(s) with your company that serve(s) as SGC’s primary contact. List the name and title of those persons in the company who will be taking an active management role in the business arrangement with SGC. E. List any present or past business associations your company has had with any other business entity involved in the racing, gaming, casino or lottery industries. Provide the business name and a brief description of the business relationship. This is trial version www.adultpdf.com 63 3. BUSINESS INFORMATION If business is a corporation, complete section A; if business is a partnership, complete section B. SECTION A – CORPORATION (1) Name and Address of Corporation as filed in the current Articles of Incorporation: ______________________________________ ______________________________________ ______________________________________ (2) Place of Incorporation _____________________________ (3) Date and Year of Incorporation _________________________ (4) Current Board of Directors and Key Officers: (Chief Executive Officer, President, Secretary, Treasurer, Chief Operating Officer, and Chief Financial Officer) ____________________________________ Name Address Title _____________________________________ Name Address Title ______________________________________ Name Address Title ______________________________________ Name Address Title _______________________________________ Name Address Title (5) Please provide the following information on all shareholders owning over 5% of the current issued and outstanding shares of the business. _______________________________________ Name Address Title _______________________________________ Name Address Title _______________________________________ Name Address Title ______________________________________ Name Address Title This is trial version www.adultpdf.com 64 (6) If applicable, list the parent company and all subsidiary companies of your business. Provide for each company the information requested below: Company Name Address Telephone Principal Officer Description of Business Affiliation (parent or subsidiary) _________________________________________________ Company Name Address Telephone Principal Officer Description of Business Affiliation (parent or subsidiary) __________________________ Company Name Address Telephone Principal Officer Description of Business Affiliation (parent or subsidiary) _______________________________ (7) If applicable, provide name of stock exchange and trading symbol for all publicly traded companies. _________________________________________________________________________________ _________________________________________________________________________________ SECTION B – PARTNERSHIP (1) Name and Address of Partnership in current Partnership Agreement __________________________ ______________________________________________________________________________ ______________________________________________________________________________ (2) Place Partnership was formed: __________________________________ Date: ________________ (3) Original or Founding Partners: __________________________________________ Name Address ____________________________________________ Name Address ___________________________________________ Name Address This is trial version www.adultpdf.com . (Chief Executive Officer, President, Secretary, Treasurer, Chief Operating Officer, and Chief Financial Officer) ____________________________________ Name Address Title _____________________________________