66 B. Has this business ever had a license revoked or suspended or an application withdrawn? YES _____ NO ______ If YES, provide details. List all cases without exception. C. In relation to the business arrangement with Scientific Games Corporation (“SGC”), is your company required to obtain any gaming or business related authorizations or licenses? YES _____ NO ______ If yes, list the name, address, and phone number of the governmental agency and the type of license or authorization required. Indicate the date the company filed or plans to file the application for licensing or approval. 6. CRIMINAL INFORMATION AND LITIGATION A. Has the Business, any of its subsidiaries, or any of its Control persons ever been INDICTED or CONVICTED of any criminal offense (except MINOR traffic violations)? YES _____ NO _____ If YES, provide details. List all cases without exception. B. Has the Business, any of its subsidiaries, or any of its Control Persons ever been the subject of, requested to testify before, or been subpoenaed to produce documents by a GRAND JURY or CRIMINAL INVESTIGATION? YES ______ NO ______ If YES, provide details. List all cases without exception. C. Has the Business, any of its subsidiaries, or any of its Control Persons ever been involved in any material civil litigation which was based in whole or in part on conduct which allegedly violated a state or federal law or sought civil damages in an amount exceeding $250,000? YES _____ NO ______ If YES, complete the following: Plaintiff / Defendant Court & Case Number City, County & State Disposition D. Has the Business, any of its subsidiaries, or any of its Control Persons been the subject of any order, judgment, or decree of any court of competent jurisdiction permanently or This is trial version www.adultpdf.com 67 temporarily enjoining it from otherwise limiting its participation in any type of business, practice, or authority? YES _____ NO _____ 7. RELATIONSHIP WITH GOVERNMENT OFFICIALS A. Is any director, officer, employee or agent of your company (a) an officer or employee of a domestic or foreign government, agency, ministry or instrumentality thereof, (b) an officer or employee of a government-owned or government-controlled entity, (c) an officer or employee of a public international organization, or (d) an officer, employee, or official of a domestic or foreign political party? YES _____ NO _____ If yes, provide details. B. Is any immediate family member (spouse, child, parent, etc.) of a director, officer, employee, or agent of your company (a) an officer or employee of a domestic or foreign government, agency or ministry, (b) an officer or employee of a government-owned or government-controlled entity, (c) an officer or employee of a public international organization, or (d) an officer, employee, or official of a domestic or foreign political party? YES _____ NO _____ If yes, provide details. C. Does any officer or employee of a domestic or foreign government, agency, ministry, or officer or employee of a government-owned or government-controlled entity, officer or employee of a public international organization, or officer, employee, or official of a domestic or foreign political party have any interest or stand to benefit in any way as a result of your proposed agreement to work with Scientific Games or any of its subsidiaries? YES _____ NO _____ If yes, provide details. 8. FINDER OR BROKER FEE Is the Business paying any broker, finder or other person a fee or compensation of any kind for this business arrangement with SGC? YES _____ NO _____ If YES, provide details. 9. FINANCIAL INFORMATION Attach FINANCIAL STATEMENTS of the business for the most recent fiscal year end. If the business or any of its subsidiaries are publicly traded companies, please attach the most recent proxy statement. List separately any major creditors of the business that are not commercial lending institutions or regulated credit facilities. This is trial version www.adultpdf.com 68 UPON COMPLETION PLEASE E-MAIL OR FACSIMILE THE PERSONAL DISCLOSURE AND AUTHORIZATION FOR RELEASE OF INFORMATION FORMS TO: Robert Kelly Compliance Investigator Scientific Games Corporation 1500 Bluegrass Lakes Parkway Alpharetta, Georgia Telephone (770) 664-3894 Fax (678) 762-5755 Email: bob.kelly2@scientificgames.com Mary Kathryn Wright Compliance Coordinator Scientific Games Corporation 1500 Bluegrass Lakes Parkway Alpharetta, Georgia Telephone (678) 297-5548 Fax (678) 762-5755 Email: mary.wright@scientificgames.com Christine Garofola Compliance Coordinator Scientific Games Corporation 1500 Bluegrass Lakes Parkway Alpharetta, Georgia Telephone (770) 664-3822 Fax (678) 762-5755 Email: christine.garofola@scientificgames.com NOTE: To expedite your required background investigation, you may FAX or EMAIL the completed Personal Disclosure and Authorization to Release Information forms. This is trial version www.adultpdf.com 69 RELEASE AUTHORIZATION – BUSINESS ENTITY To all Courts, Banks, Financial and Other Institutions, and all Governmental Agencies – federal, state, and local, without exception, both foreign and domestic. ________________________________________ has authorized Scientific Games Corporation to (Name of Business Entity) conduct a full investigation into its background and activities. Therefore, you are hereby authorized to release any and all information pertaining to ______________________________________, documentary or otherwise, as requested by an appropriate (Name of Business Entity) employee of the Scientific Games Corporate Legal Department or an independent investigator engaged by Scientific Games. This authorization shall supersede and countermand any prior request or authorization to the contrary. A photostatic copy of this authorization will be considered as effective and valid as the original. The undersigned is authorized to sign this Release Authorization on behalf of _____________________________________. (Name of Business Entity) SIGNATURE: _____________ Print Name: _____________ Title: ________________ (Domestic) This is trial version www.adultpdf.com 70 ATTACHMENT C – M/F/DBE REQUIRED FORM BEP UTILIZATION PLAN The BEP Utilization Plan must be submitted with RFP. (the Bidder) must submit the following BEP Utilization Plan as part of the RFP in accordance Sections 1.16 and 2.2 of the RFP. (the Bidder) makes the following assurance and agrees to include the assurance in each subcontract with a subcontractor or supplier utilized on this contract: Name: _________________________________________________________________________ Title: __________________________________________________________________________ Telephone: ( _) extension___________ Email: _________________________________________________________________________ We submit one (1) of the following statements: We are certified (or are eligible and have applied to be certified) with BEP and plan to fully meet the BEP utilization goal through self-performance. We attach Section I to demonstrate our Plan fully meets the BEP Utilization Goal of 20% through subcontracting. We attach Section I to detail that we do not fully meet the M/F/DBE utilization goal. We also attach Section II, Demonstration of Good Faith Efforts. Section I Utilization of Certified Vendors Please submit a separate Section I for each proposed certified vendor. To achieve the BEP utilization goal through subcontracting, the following is proposed: 1) The proposed certified vendor‘s company name, address and phone number: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ _____ Attach separate sheet, if utilizing more than one (1) BEP Firm At the time of submission, the above certified vendor is: Certified with the CMS Business Enterprise Program (BEP) Meets the criteria and has submitted an application for certification with BEP This is trial version www.adultpdf.com 71 (BEP certification must be completed before contract award) Certified as a disadvantaged, minority, or woman business enterprise with the following governmental agency or private organization: (BEP certification must be completed before contract award) ____________________________________________________________________________ ____________________________________________________________________________ 2) Statement of Work (SOW) ____________________________________________________________________________ ____________________________________________________________________________ 3) The total estimated cost to Northstar for this contract is $ . The portion of the contract which will be subcontracted to BEP certified vendor(s) is $ , or % of the total cost of the contract. Section II Demonstration of Good Faith Efforts to Achieve BEP Subcontracting Goal If the BEP subcontracting goal was not achieved, the Good Faith Efforts checklist must be completed The Vendor will promptly provide evidence in support of its Good Faith Efforts to Northstar upon request. Good Faith Efforts Checklist Insert on each line below the initials of the authorized Vendor representative who is certifying on behalf of the Vendor that the Vendor has completed the activities described below. If any of the items below were not completed, attach a detailed written explanation why each such item was not completed. If any other efforts were made to obtain BEP participation in addition to the items listed below, attach a detailed written explanation. _____ Identified portions of the project work capable of performance by available BEP vendors, including, where appropriate, breaking out contract work items into economically feasible units to facilitate BEP participation even when the Vendor could perform those scopes with its own forces. _____ Solicited through reasonable and available means (e.g., written notices, advertisements) BEP vendors to perform the types of work that could be subcontracted on this project, within sufficient time to allow them to respond. _____ Provided timely and adequate information about the plans, specifications and requirements of the contract. Followed up initial solicitations to answer questions and encourage BEP vendors to submit proposals or bids. ____ Negotiated in good faith with interested BEP vendors that submitted proposals or bids and thoroughly investigated their capabilities. This is trial version www.adultpdf.com 72 ____ Made efforts to assist interested BEP vendors in obtaining bonding, lines of credit, or insurance as may be required for performance of the contract (if applicable). ____ Utilized resources available to identify available certified vendors. BIDDER By: Its: Date: This is trial version www.adultpdf.com 73 ATTACHMENT D - DEVIATIONS AND EXCEPTIONS Name of Bidder: Bidder shall complete and submit this Attachment with Bidder‘s Proposal if Bidder proposes to deviate from or take exception to any of the RFP requirements. Bidder must identify each such deviation and exception and describe the nature and extent thereof, providing the information in order of the RFP in the following format: RFP Section No. Subject Heading Deviation or Exception This is trial version www.adultpdf.com . business arrangement with SGC? YES _____ NO _____ If YES, provide details. 9. FINANCIAL INFORMATION Attach FINANCIAL STATEMENTS of the business for the most recent fiscal year end. If the. version www.adultpdf.com 69 RELEASE AUTHORIZATION – BUSINESS ENTITY To all Courts, Banks, Financial and Other Institutions, and all Governmental Agencies – federal, state, and local,