DEPARTMENT OF JU ICEREPEALED PA 1 of2

MAJOR LEAGUE SPORTS RAFFLE UNPAID VOLUNTEER or INDIVIDUAL AFFILIATED PERSON

ANNUAL REGISTRATION FORM MAIL To ·. FOR CALENDAR YEAR 20

Bureau of Gambling Control P. 0 . Box 168024

Sacramento, CA 95816-8024 Pho : (91 6) 227-3584; Fax (916) 227-0170

regulations conce ing major league sports raffles in the State of California.

SECTION 1: APPLICANT INFORMATION

Applicant's First Name Last Name Middle Initial

Government Issued Identification Inform ion Date of Bi

Home Address (no. and street name) City Zip Code Daytime Telephone Number

Mailing Address (no. and street name) City Zip Code Alternative Contact Telephone#

SECTION 2: ELIGIBLE ORGANIZATION AFFILIATION INFORMATION

Name of Eligible Organization

Eligible Organization Address (no. and street name) .-------.IState Zip Code

Federal Tax ID E-Mail Address (if pplicable) Telephone Number

SECTION 3: ELIGIBLE RECIPIENT ORGANIZATION INFORMATION

Name of Eligible Recipient Organizatio

Eligible Recipient Organization City State Zip Code

Federal Tax ID E-Mail Address (if applicable)

SECTION 4: CERTIFICATION I declare under penalty f perjury under the laws of the State of California that the foregoing information, and all information submit! d with this application, is true, correct, and co lete. I understand that the information I have provided on this form will be verified with either the eligible organ ation or the eligible recipient organizati as part of the registration process. Additionally, I agree to comply with all applicable laws, local ordinances, and a inistrative

First Name Last Name

Printed ame

Date: Si nature: ---------------------­

STATE OF CALIFORNIA DEPARTMENT OF JU ICE GC201 REPEALED

PA 2of2 ( ev 08/2016 Ori~ 81/2916)

MAJOR LEAGUE SPORTS RAFFLE UNPAID VOLUNTEER or INDIVIDUAL AFFILIATED PERSON

ANNUAL REGISTRATION FORM

Privacy Notice on Data Collection Forms As Required by Civil Code § 1798.17

Collection and U of Personal Information The Division of Law nforcement, Bureau of Gambling Control in the Departme of Justice collects the information requested n this form as authorized by California Penal Code se ,on 320.6. The Bureau uses this information to tablish grounds for the license, permit or other ap oval indicated on this application form. In additi , any personal information collected by state encies is subject to the limitations in the Information ractices Act and state policy. The Depart ent of Justice's general privacy policy is available at htt ://oa . a. ov/ rivac - olic .

Providing Personal Information All the personal information requeste in this form must be provi ed.

Access to Your Information You may review the records maintained by he Division of aw Enforcement, Bureau of Gambling Control in the Department of Justice that con in your pe sonal information as permitted by the Information Practices Act. (See below for cont ct infor ation.)

Possible Disclosure of Personal Information In order to process your application, we may nee to hare the information you give us with law enforcement or regulatory agencies.

The information you provide may also bed ' closed in the f lowing circumstances:

With other persons or agencies here necessary to perf m their legal duties, and their use of your information is compatible nd complies with state law, such has for investigations or for licensing, certification, or re latory purposes;

To another government gency as required by state or federal la

Contact Information For questions about this otice or access to your records, you may contact th Special Agent Supervisor of Special Programs at e Department of Justice, Bureau of Gambling Control, t P. 0 . Box 168024, Sacramento, CA 95 6-8024, (916) 227-3584 or e-mail at Gamblin Control do . a. ov

DEPARTMENT OF JUSTICE REPEALED PAGE 1 o

MAJOR LEAGUE SPORTS RAFFLE MANUFACTURER AND DISTRIBUTOR OF PRODUCTS OR SERVICES

ANNUAL REGISTRATION FORM FOR CALENDAR YEAR 20

MAIL TO: ureau of Gambling Control

P. 0. Box 168024 Sac mento, CA 95816-8024

Phone: (916) 7-3584; Fax (916) 227-0170

Pursuant to California Pena Code section 320.6, requires manufacturers and distributors, who pr ide raffle-related products or services to eligible organi tions that conduct major league sports raffle(s) to register an ally with the Department of Justice. This form shall be used y manufacturers and distributors who provide raffle-related oducts or services to apply for registration with the Department o ustice.

Please type or print (in ink) all informa ·on requested on this form. A $5,000 Annual Re stration Fee must accompany this form. Make check or money order pa able to the California Department of Justi .

SECTION 1: ENTITY INFORMATION

Applicant's First Name Last Name Middle Initial Title

Business Name D rng Business As (if different than Business Name)

Business Address (no. and street name) City Zip Code

Zip Code

Business Telephone Number

City Business Fax NumberMailing Address (no. and street name)

Business License Expiration Date City or County of Business License

Federal Tax ID bsite Address (if applicable)

SECTION 2: RAFFLE-RELATED PRODUCTS AND SERVICES

Please indicate the products and/or ervices that the business provides:

D Electronic Accounting & R orting System Software D Electronic Raffle Tic t Sales Printer

D Electronic Accounting & eporting System D Electronic Raffle Ticket aper

D Electronic Raffle Sys m Security Component D Counterfoil Container

D Electronic Raffle stem Server D Admission-style Raffle Ticket

D Electronic Ra System Server Software D Wide Area Network Component

D Electronic ffle Ticket Sales Device

Other

DEPARTMENT OF JUSTICE REPEALED PAGE 2o

MAJOR LEAGUE SPORTS RAFFLE MANUFACTURER AND DISTRIBUTOR OF PRODUCTS OR SERVICES

ANNUAL REGISTRATION FORM

SECTION 3: MANUFACTURER LICENSE INFORMATION If additional space is needed, please attach a listing of the requested information on a separate sheet of paper.

Has the equipment bei registered been licensed with any gaming agency, including any other state, · , county, federal, or country agency?

Yes. Please list the gaming agen and 0No D license information in the follo · g table

Gaming Agency Name License Number from that Agency Expiration Date

I declare under penalty of perjury under the laws of State of California that the foregoing information, and all information submitted with this application ·s tru correct, and complete. Additionally, our business and its representatives agree to comP, with all pplicable laws, local ordinances, and administrative regulations concerning major I gue sports ffles in the State of California.

First Name Last Name Middle Initial

Printed Name

Date: Signature: ---------+----------­

DEPARTMENT OF JUSTICE REPEALED PAGE 3o

MAJOR LEAGUE SPORTS RAFFLE MANUFACTURER AND DISTRIBUTOR OF PRODUCTS OR SERVICES

ANNUAL REGISTRATION FORM

Privacy Notice on Data Collection Forms As Required by Civil Code§ 1798.17

Collection and Use f Personal Information The Division of Law En rcement, Bureau of Gambling Control in the Department f Justice collects the information requested on his form as authorized by California Penal Code secti n 320.6. The Bureau uses this information to est lish grounds for the license, permit or other appr val indicated on this application form. In addition, ny personal information collected by state a ncies is subject to the limitations in the Information Pr ctices Act and state policy. The Departm nt of Justice's general privacy policy is available at htt ://oa .ca. ov/ rivac - olic .

Providing Personal Information All the personal information requested I this form must be provid d.

Access to Your Information You may review the records maintained by tfi Division of w Enforcement, Bureau of Gambling Control in the Department of Justice that conta1 your per onal information as permitted by the Information Practices Act. (See below for contac infer ation.)

Possible Disclosure of Personal Information In order to process your application, we may nee re the information you give us with law enforcement or regulatory agencies.

The information you provide may also bed. closed in the foll wing circumstances:

With other persons or agencies ere necessary to perfor their legal duties, and their use of your information is compatible nd complies with state law, ch has for investigations or for licensing, certification, or re latory purposes;

To another government gency as required by state or federal law.

Contact Information For questions about this otice or access to your records, you may contact the pecial Agent Supervisor of Special Programs a he Department of Justice, Bureau of Gambling Control , P. 0 . Box 168024, Sacramento, CA 95 16-8024, (916) 227-3584 or e-mail at Gamblin Control do·. . ov

STATE OF CALIFORNIA DEPARTMENT OF JUSTI GC 203 REPEALED

PAGE 1 12 ( V. 0812016 Orig 011,1016} MAJOR LEAGUE SPORTS RAFFLE

AFFILIATED PERSON ANNUAL REGISTRATION FORM FOR CALENDAR YEAR 20

MAIL TO: Bureau of Gambling Control

P. 0. Box 168024 Sacramento, CA 95816-8024

Phon : (916) 227-3584; Fax: (916)227-0170

Pursuant to Califorrn Penal Code section 320.6, person(s) affiliated with an eligible organization wh conduct major league sports raffle(s) must re ister annually with the Department of Justice. This form is only for an eligib organization to register its affiliated persons. If additional sheet is needed, please attach a listing of the requested infer ation on a separate sheet of paper.

Please type or print (in ink) all · formation requested on this form . A nonrefundable $10 A ual Registration Fee for each affiliated person listed in Se ct , n 2 must accompany this form. Make check or mon order payable to the California Department of Justice.

SECTION 1: INFORMATION

Eligible Organization Team or Associaf n Affiliation

Fiduciary's First Name Last Name Middle Initial Daytime Telephone Number

Eligible Organization Address (no. and street name) State Zip Code

Mailing Address, if different (no. and street name) State Zip Code

SECTION 2: RAFFLE-RELATED DUTIES

Please indicate with an "X" in the appropriate box the raff

Employee's First Name Last Name Raffle System Raffle Ticket

Government Management Seller

Issued ID

DEPARTMENT OF JUSTI REPEALED PAGE 2 12

MAJOR LEAGUE SPORTS RAFFLE AFFILIATED PERSON ANNUAL REGISTRATION FORM

SECTION 3: CERTIFICATION

I declare under pe alty of perjury under the laws of the State of California that the foregoing information, d all information submitted with this plication is true, correct, and complete. I understand that the information I have pr. vided on this form will be verified with th eligible organization as part of the registration process. I agree to comply wit all applicable laws, local ordinances, and a inistrative regulations concerning major league sports raffles in the State f California.

Last Name Middle Initial

Fiduciary's Printed Name

Fiduciary's Signature: ______...,..._____________-+ Date:

Notice on Data Collectio Forms quired by Civil Code§ 1 98.17

Collection and Use of Personal lnformati The Division of Law Enforcement, Bureau of G mbling Cont I in the Department of Justice collects the information requested on this form as authorized y Califo ia Penal Code section 320.6. The Bureau uses this information to establish grounds for the license, per it or other approval indicated on this application form. In addition, any personal information collected state agencies is subject to the limitations in the Information Practices Act and state policy. The DeP, rt ent of Justice's general privacy policy is available at http://oag .ca.gov/privacy-policy.

Providing Personal Information All the personal information requested in thi form must be pro ·ded.

Access to Your Information You may review the records maintain by the Division of Law Enfor ment, Bureau of Gambling Control in the Department of Justice that cont ·n your personal information as pe itted by the Information Practices Act. (See below for contact infor ation.)

Possible Disclosure of Pers nal Information In order to process your ap 1cation, we may need to share the information you ive us with law enforcement or regulatory agencies.

The information you ovide may also be disclosed in the following circumstances:

With other ersons or agencies where necessary to perform their legal duties, and eir use of your informaf n is compatible and complies with state law, such has for investigations or r licensing, certifi tion , or regulatory purposes;

To nether government agency as required by state or federal law.

For: uestions about this notice or access to your records, you may contact the Special Agent Supervise of S ecial Programs at the Department of Justice, Bureau of Gambling Control, at P. 0 . Box 168024,

acramento, CA 95816-8024, (916) 227-3584 or e-mail at GamblingControl@do j.ca.gov

6 STATE OF CALIFORNIA DEPARTMENT OF JUSTICE

PAGi;.A"'of 4 MAJOR LEAGUE SPORTS RAFFLE ~ 016 0!(Rev . ~ ,g .c»/2016) REPEALED ELIGIBLE ORGANIZATION ANNUAL REPORT PLEASE SEND COMPLETED REPORT TO: Bureau of Gambling Control P. 0 . Box 168024

cramento, CA 95816-8024 Phone: 916-227-3584; Fax (916) 227-0170

Annual Report Period:

Eligi~Organization's Name: -­

Eligible Organization's Registration Nu

--­--­-­---­-----­------'---­--­

Pursuant to Penal Code section 320.6, bdivision (o)(12)(A), once registered, an eligible organi ion shall file annually thereafter with the Department of Justice a report that incl es all of the following information for each of the igible orga,:iization's last three fiscal years. Pursuant to Penal Code section 320.6, subdiv1 · n (0)(12)(8), failure to submit the annual port shall be grounds for denial of an annual registration.

REGULATION/STATUTE

(i) The aggregate gross receipts from the operation of raffles.

(ii) The aggregate direct costs incurred by the eligible organization from the operation of raffles .

(iii) The charitable or beneficial purposes for which proceeds of the raffles were used.

(iv) The aggregate distributions of proceeds from the operation of raffles made to directly support benefic· or charitable purposes, other than beneficial or ch · able purposes undertaken by the eligible organiz ·on, or eligible recipient organizations, under Penal Cod section 320.5, subdivision (c) .

(v) The aggregate distribution)Yf>f proceeds from the operation of raffles made tJ;Yraffle winners.

(vi) The aggregate · tributions of proceeds from the operation of ra made to any other organizations, or for any other pu oses, other than those included in items (ii} , (iv) , and above.

Year 1 Year2

to

Year3

to

DEPARTMENT OF JUSTICE

PAG!;..!"ot 4 MAJOR LEAGUE SPORTS RAFFLE REPEALED ELIGIBLE ORGANIZATION ANNUAL REPORT

Year2

to

Year3

to

Year 1

to REGULATION/STATUTE

(vii) A schedule of distrib ·ons of proceeds from the operation of raffles, by indivi al raffle, made to eligible recipient organizations under Pe I Code section 320.5, subdivision (c), that are not affiliate ith the eligible organization.

(viii) A schedule of distributions of proceeds operation of raffles, by individual raffle, made to recipient organizations under Penal Code section 3 subdivision (c) , that are affiliated with the eligible organization.

(ix) A schedule of distributions of proceeds from the operation of raffles, by individual raffle, made to any other organization not included under items (vii) or (viii) above, or for beneficial or charitable purposes undertaken by the eligible organization.

(x) The aggregate gross receipts from activities other than the operation of raffles .

(xi) The aggregate costs incurred by the eligible organizatio from activities other than the operation of raffles.

(xii) The aggregate distributions of funds other n proceeds from the operation of raffles made to direct! upport beneficial or charitable purposes or eligi recipient organizations under Penal Code sec · n 320.5, subdivision (c).

(xiii) The aggregate distrib · ns of funds other than proceeds from the oper on of raffles for purposes other than those listed in i ms (xi) and (xii) above.

STATE OF CALIFORNIA DEPARTMENT OF JUSTICE

PAG~ of48~04 MAJOR LEAGUE SPORTS RAFFLE (Rev ~ 016 O<tg--0,1/2016) REPEALED ELIGIBLE ORGANIZATION ANNUAL REPORT

Year2 REGULATION/STATUTE

(xiv) A schedule of distributi on of funds other than proceeds from the operation of raffles made eligible recipient organizations under Penal C ode sec 320.5, subdivision (c) , that are not affiliated wit h the eligible ganization.

(xv) A schedule of distributi ons of funds other t~proceeds from the operation of raffles made to any other ?.r~~ation not included under item (xiv ) above, or for beneficial or charitable purposes underta ken by the eligible organizatio

Year 1

to to

Year3

to

NOTE: The department shall make the reports required by this ragraP, available to the public via the online search portal of the Attorney General's Registry of Charitable Trusts maintained pursua o Section 12584 of the Government Code.

CERTIFICATION

I declare under penalty of perjury under the laws he State of California that the foreooing information is true, cor rect, and complete.

First Name Last Name ~ Middle Initial

Fiduciary's Printed Name

Fiduciary's Signature: Date:

DEPARTMENT OF JUSTICE

PAGUof 4MAJOR LEAGUE SPORTS RAFFLE REPEALED ELIGIBLE ORGANIZATION ANNUAL REPORT

Privacy Notice on Data Collection Forms As Required by Civil Code § 1798.1 7

Collection and Use of Personal Information ' Bureau of Gambling Control in the Department of Justice collects the i rmation requested on this form

as authorized by California Penal de section 320.6. The Bureau uses this information to establish unds for the license, permit or other approval indicated on this applic ·on form. In addition, any personal information collected b tate agencies is subject to the limitations in the Information Practices Ac nd state policy. The Department of Justice's gener privacy policy is available at http://oag. ca .gov/privacy-policy.

Providing Personal Information All the personal information requested in this form mus~ provided.

Access to Your Information

aotices Act. You may review the records maintained by the Division of Law En ent, Bureau of Gambling Control in the Department of Justice that contain your personal information as permitted by the Information (See below for contact information.)

Possible Disclosure of Personal Information In order to process your application, we may need to sl)ar'e the information you gi\(e us with law enforcement or regulatory agencies.

The information you provide may also be disclo~ in the following circumstances:

With other persons or agencies w~e necessary to perform their legal duties, and their~e of your information is compatible and complies with state law, such 1J,asfor investigations or for licensing, certification, or regulat~purposes;

To another government_fagency as required by state or federal law.

Contact Information For questions about is notice or access to your records, you may contact the Special Agent Supervisor of Specia~ograms at the Department of J ice, Bureau of Gambling Control , at P. 0 . Box 168024, Sacramento, CA 95816-8024, (916) 227-35

ol@doi.ca.aov

DEPARTMENT OF JUSTIC REPEALED PAGE 1 12

MAJOR LEAGUE SPORTS RAFFLE ELIGIBLE ORGANIZATION RAFFLE REGISTRATION FORM

FOR CALENDAR YEAR 20

MAIL TO: Bureau of Gambling Control

P. 0 . Box 168024 acramento, CA 95816-8024

Phone: ( 16) 227-3584; Fax (916) 227-0170

Pursuant to Californi Penal Code section 320.6, an eligible organization that wishes to cond t major league sports raffle(s) must re ister the raffle(s) with the Department of Justice. This form is for th egistration of raffle(s) for regular season and p st-season home games.

Please type or print (in ink) a information requested on this form. A nonrefundable$, 00 Registration Fee for each raffle listed in Section must accompany this form. Make check or mon order payable to the California Department of Justi e.

SECTION 1: ELIGIBLE ORGANIZATION INFORMATION

Team or Associatio Affiliation Eligible Organization

Last Name iddle Initial Daytime Telephone Number Fiduciary First Name

State Zip Code Eligible Organization Address (no. and street name)

City State Zip Code E-Mail Address (if applicable)Mailing Address (no. and street name)

SECTION 2: RAFFLE REGISTRATION

1t, Eligible Organization For Which Raffle Is Being Event Date Event Location Conducted

llL---_ '---------+-' ~-----­- ---'

IL...--1- '-------+---' ~-­--------'

I L...- ­1 - .________, ~---------'r---------'

I L...- ­1 - ~ ­ ---' ~--- ­ -------'.-- ­ ­ - ---'

I L...- ­1 - '------,<------' ~­- --------'

I L...- ­1 - -------'~­- --­-------'<-­- ---'

I'----------+-' ---- ­ '------ ­ - ­ --~ ,.____________,, ._______'-------­-­-----',-­~

,..______,._____ ~~ '--------~

---------

DEPARTMENT OF JUSTIC REPEALED PAGE2 12

MAJOR LEAGUE SPORTS RAFFLE ELIGIBLE ORGANIZATION RAFFLE REGISTRATION FORM

SECTION 3: CERTIFICATION

I declare under pen lty of perjury under the laws of the State of California that the foregoing information, d all information submitted with this ap lication is true, correct, and complete. I understand that the information that I hav provided on this form will be verified wit the eligible organization as part of the registration process. I agree to compl};'. ith all applicable laws, local ordinances, a administrative regulations concerning major league sports raffles in the ate of California.

Firs Name Last Name Middle Initial

Fiduciary's Printed Name

Fiduciary's Signature: _______.....,.________________, Date:

Collection and Use of Personal lnformatio The Division of Law Enforcement, Bureau of G bling Contr in the Department of Justice collects the information requested on this form as authorized Califor ·a Penal Code section 320.6. The Bureau uses this information to establish grounds for the license, erm· or other approval indicated on this application form. In addition, any personal information collected tate agencies is subject to the limitations in the Information Practices Act and state policy. The Depa ent of Justice's general privacy policy is available at http://oag.ca.gov/privacy-policy.

Providing Personal Information All the personal information requested in this rm must be pro · ed.

Access to Your Information You may review the records maintained y the Division of Law Enforc ment, Bureau of Gambling Control in the Department of Justice that contai our personal information as per itted by the Information Practices Act. (See below for contact informa on.)

Possible Disclosure of Perso I Information In order to process your appli tion, we may need to share the information you ive us with law enforcement or regulatory agencies.

The information you pro 1de may also be disclosed in the following circumstances:

With other p sons or agencies where necessary to perform their legal duties, and eir use of your informatio s compatible and complies with state law, such has for investigations or or licensing, certificati n, or regulatory purposes;

To a ther government agency as required by state or federal law.

Contac nformation For q stions about this notice or access to your records, you may contact the Special Agent Supervis of Spe al Programs at the Department of Justice, Bureau of Gambling Control, at P. 0. Box 168024, S ramento, CA 95816-8024, (916) 227-3584 or e-mail at GamblingControl@doj.ca.gov

STATE OF CALlffiRNIA REPEALED ~ \ 6 Oliy. Q1/2Q1ti)(Rev 11 MAJOR LEAGUE SPORTS RAFFLE

ELIGIBLE ORGANIZATION - EQUIPMENT REGISTRATION FORM

BUREAU OF GAMBLING CONTROL P. 0 . Box 168024~

~ sacmmanto, CA 95816-8024

Phone: (916) 2.27-3584; Fox: (916) 227-0170

Pursuant to Californi Penal Code section 320.6, subdivision (o)(3), an eligible organizations II register the equipment used in the le and distribution of raffle tickets, and shall have the equipment te ed by an independent gaming test laboratory. is form Is used tor the eligible organization to register the equiP, ent used In the sate and distribution of raffle tickets.

SECTION 1 - Eligible Organization Information Eligible Organization/feam Of Association A i • lion Name:

Zip CodeCity StateAddress (Numbers/Street)

City Zip CodeMailing Address (if differant than above) State

Fax Number Web AddressPhone Number

Fiducialy Name

Phone Number Fax Number ~-Mail Adoress

SECTION 2 - Manufacturer License Information If additional space is needed, please attach a fisting of the requested Information on a separate sheet of paper.

Has the equipment being registered been nsed with any gaming agency, lncludin any other state, city, oounty, ·feden~I . or country agency? D Yes. Please list the . ming agency and 0No license Information In t e following table

Gaming Agency N@me License Nt.,mber from that Agency E~piration Date

STAIE Of CALIFORNIA REPEALED ~PAA-7 MAJOR LEAGUE SPORTS RAFFLE

fl "

ELIGIBLE ORGANIZATION ~ EQUIPMENT REGISTRATION FORM \ """"'"' SECTION 3 ~ Equipment Information

Complete the information below for ea.ch equipment model and Its designated software vel'$lon you are registering p1Jl'$l,umt to Penal Code section 320.6, subdivision (o)(3). If you a.re requesting approval for more than three pieces of equipment, please make an additional copy of

this page and attach to the a.pplica.tlon.

Model Ntlme \ Model Number

Software (Firmware) version \ SoftwQre (Fkmwere BuJld Del!>) / I

Answer the following questions re~ding the equipment model and its designated software~ rsion (If applicable) listed above.

1. Description of equipment: I \ / 2. Has the model and software version>~ previously tested or certified by an indj9°dent gaming test

laboratory? If yes, attach DYES copies of . rtification documents. ONO

3. Is this equipment model leased by your o~nization? I DYES O NO

4. Is this equipment model owned by your orga~tion? I DYES O NO

'\ /

Model Name

So\ vel Number

/ ftware (Firmware) Vemion

~Softwllre (f irmwore Build Date)

\ Answer the following questions regarding the equipmen~odel and it~ esignated software version (if applicable) listed above.

1. Description of equipment: j / \ 2. Has the model and software version been p~~usly tested or certified b~ independent gaming test

laboratory? If yes, @ttach copies of certifi tion doc1.1ments, DYES D NO

3. Is this equipment model leased by your o~niiation? \ 0 VES O NO

4. Is this equipment model owned by yo7rganization?

/ \ DYES O NO

" Model Nome I Model Number

SoftwQre !Fllll1Wll,.) Vera~n; Softw!lr-a (Flrmwore Bullet Date) \

Answer the followln~uestions regarding the equipment model and Its designated software version \ (If apP!l?able) listed above.

1. Description of yquipment: I \ 2. Has the ~/ and software version been previously tested or oertlfied by an Independent gaming test

laborato If yes, attach O NO copie.s of certlfh:ation documents, 0~

3. Is this j<fuipment model leased by your org1ml2atlon? D VEs\ o NO 4. 1s7 equipment model owned by your organization?

D YES ~o

I \

16 G,ig. Q1RQUi) REPEALED

MAJOR LEAGUE SPORTS RAFFLE ELIGIBLE ORGANIZATION - EQUIPMENT REGISTRATION FORM

SECTION 4 • CERTIFICATION / SIGNATURE A fiduciary of the eligible organi~ation must sign on behalf of the eligible organl2!atlon.

I certify under p alty of petjury under the laws of the State of California that I have personally com ted this form and know that the cont. ts thereof, the Information contained herein and In any attachments, Is true, ac rate, and complete, I a/so certify that any qulpment and Its designated software version Indicated on this form meets e requirements of the Major League Sports R · e Program regulations and understand that the approval Is subject to following conditions:

(1) Any equipment used I the sale and distribution of raffle tickets must be from a manufa urer or distributor registered with the Dep .ment ofJustice, pursuant to Penal Code section 320. 6.

(2) Registration ofequipment nd any associated software has no bearing on the ques n of whether the manufacturer orcllstrfbutor the device, or any person afflllatecl with the manu turer or distributor of the device, will qualify for lssuan ofany registration. Any approval will be cancell 'd In the event that the manufacturer or distributor of th device Is subsequently determined to be In iglble for registration.

Fldulclary's Signature

Fiduciary's Printed Name

16 Orig. 01 li!lll6)

REPEALED MAJOR LEAGUE SPORTS RAFFLE

ELIGIBLE ORGANIZATION ,. EQUIPMENT REGISTRATION FORM

Privacy Notice on Data Collection Forms As Required by Civil Code § 1798.17

o e t on of P I r o w Enforcement. Bureau of GambliThe Division of L ng Control in the Department of Jus · e collects the

information reques d on this form as authorized by California Penal Code section 320 . The Bureau uses this information establish grounds for the license, permit or other approval in cated on this application form. In ad 'tion. any personal information collected by state agencies ·s subject to the limitations in the In-format n Practices Act and state policy. The Department of stice1s general privacy policy is available at htt :// ov/ rivac - olic .

ted in this form must be provided.

Access to Your Information You may review the records maintaine y the Division of Law En . rcement1 Bureau of Gambling Control in the Department of Justice that Information Practices Act.

Possible Disclosure of Personal

ntain your personal i (See below for c ntact information.

Information In order to process your application, we may nee · to sh e the information you give us with law enforcement or regulatory agencies.

The information you provide may also be disclose in tH following circumstances:

· With other persons or agencies where cessary to rform their legal duties. and their use of your information is compatible and c plies with state w1 such has for investigations or for licensing. certification, or regul.ato purposes;

To another government agenc as required by state or feder law.

Contact Information For questions about this notice r .access to your records, you may con-tac the Special Agent Supervisor of Special Programs at the D. artment of Justice, Bureau of Gambling Con ol, at P. 0. Box 168024, Sacramento. CA 95816~80 ~' (916) 227-3584 or e-mail at Gamblin Control

STATE OF CALIFORNIA DEPARTMENT OF JUSTIREPEALED8 ~ 2_97 PAGE 1 13 (Orig~l/2016) Major League Sports Raffle

Electronic Raffle System and Equipment Checklist and Test Draw

BUREAU OF GAMBLING CONTROL P.O. Box 168024

Sacramento, CA 95816-8024 hone: (91 6) 227-3584; Fax: (916) 227-0170

Before using an ele tronic raffle system (system) to conduct a raffle, the eligible organization ust test the system. (Cal. Code. Regs., tit. j 1, § 2109.) Use th is checklist before each registered event to docu nt that the system is configured correctly, fu tioning properly, and fully operational. You may attach additiona pages to this form, if additional space is neede to document the test. Every eligible organization must keep e completed form, and any information attached, in luding all photographs taken, for a period of three years.

EvenWenue:

Date: Registered Event Number

Name of Fiduciary or Designated Affiliated Pe on

Equipment Information

a. Raffle Sales Unit (RSU): Make/Model and Quantity

b. Raffle ticket printers: Make/Model

c. Stand Alone Kiosk: Make/Model and Quantity

Equipment Location

e. Dedicated Server

Passwords and Access

D Verified Pas word Access to Server D Deny Remote Access During a Game D Remote Access estrictions

D RSUAc ss Controls D Firewall Configuration D Non-routable IP ad ss

Miscellaneous

Wr less Encryption D RSU Physical Security D Uniterruptible Power Supply upport D D SU Communication with Server D Backup and Recovery Procedures

STATE OF CALIFORNIA DEPARTMENT OF JUSTI REPEALEDB 207 PAGE 13 (Orig. 01/2016) Major League Sports Raffle

Electronic Raffle System and Equipment Checklist and Test Draw

Miscellaneous (continued)

D Photograph ounterfoil Printer(s) and Counterfoil Container Layout in Venue

D RSU locations (1 elude a map identifying locations sales will occur and location where RSUs not in use are sto ed

Identify personnel wi designated responsibility of any part of the system

Test Draw a. Enroll the RSU (one kiosk and two porta e devices) for a test draw*:

i. 2 portable devices configured for Wi · (If applicable) D ii. 1 kiosk connected to central system. (If plicable) D iii. Counterfoil printers online with sufficient pa er. D

*One RSU will be required to have SD card removed duri

b. Sell 100 tickets from portable devices (if in use) and/or ki D c. Void 15 tickets. D d. Close sales on RSU devices and close the test draw o D e. Select a winning number from the counterfoil contai D

i. Winner number selected D f. Complete winning number verification proce D g. Announce winning number (public addres , scoreboard, or other method use at the venue) D h. enerate, save and co ect Ra e Bea r Ticket Report and Voided Draw Num er Report in Exce ormat (pursuant to Cal. Code. Regs., tit. 11, § 02) D i. Collect all test raffle tickets. D j . the counterfoi l container. D k. Printed information on beare ticket must meet Cal. Code. Regs., tit. 11, § 2100 requiremen

1) The name of the efigibf organization conducting the raffle; 2) The Bureau-issued r gistration identification number for the eligible organization registratio 3) The location, date nd time of the corresponding raffle and manual draw; 4) The unique num r of the raffle ticket that must not be generated by a random number genera r; 5) ff different tha he eligible organization conducting the raffle, the name of the eligible recipient o anization; D 6) The stateme . "Ticket holders need not.be present to win ," and the contact information, including t e name,

phone nu er, and electronic mail address, of the eligible organization conducting the raffle; 7) The toll-f e telephone number approved by the Office of Problem Gambling (or its successors) that pr ides

inform 10n and referral services for problem gamblers, currently "1-800-GAMBLER," and 8) The · e limit for the raffle player to claim the prize, as provided in Penal Code section 320.6.

STATE OF CALIFORNIA DEPARTMENT OF JUST! REPEALEDB 207 PAGE I 3 (Orig. 01/2016) Major League Sports Raffle

Electronic Raffle System and Equipment Checklist and Test Draw

Test Draw (continued)

D ii . Sell tickets normally from a RS until printer is low on paper. Observe printer beha ·or and document any issues

D

/. Use barcod scanner to scan counterfoil tickets (if applicable). D m. Verify printed ounterfoil ticket numbers match with Raffle Bearer Ticket Report. D n. Remove raffle tic et paper from counterfoil printer or replace with low paper cartridge if available. D o. e additiona ticke unti paper runs out, or attempt to se tickets with no paper. Rep ace paper.

observations. D

D i. Insert paper roll that is low n paper into the remaining active printer. Check for low per

signal from printer.

D Replace paper when it has run out. Verify pri D Test RSU devices for non-WiFi operation. D

i. Close sales on RSUs and close the test draw o D D

iii. Select a winning number from the counterfoil contain iv. Generate, save and collect Raffle Bearer Ticket Repo § 2102)

v. Collect all test raffle tickets. D vi. Collect all counterfoil tickets from the counterf ii container. D vi. Verify printed information on bearer ticket s., tit. 11, § 2100 requirements. D

r. ow paper is not possib e, disab e a I inters. D i. Check for paper out signal from printe Paper end/red LED) and server.

s.

t.

CERTIFICATION

I certify under penalty of perjury u er the laws of the State of Calin nia that I have personally completed this form and know that the cont ts thereof, the information containe herein and in any attachments, is true, accurate, and complete.

Title

Signature Date

Fiduc· ry's Printed Name Date