SELF-LIMIT ACCESS PROGRAM MGM Resorts International is committed to promoting public awareness and education and to providing information on available resources to those patrons who believe they may have a gambling problem. MGM Resorts International maintains a program in compliance with Nevada Gaming Regulation 5.170 that allows our patrons to voluntarily self-limit themselves from certain activities and privileges, which are provided as a service and convenience to our patrons by completing this form. This self- limitation will be effective within 14 days of this request being received by MGM Resorts International. PATRON’S REQUEST TO SELF-LIMIT ACCESS1. I, the undersigned patron, hereby request to self-limit my access to casino and non-casino privileges, including receiving complimentaries. I agree that as a result of being self-limited I no longer will be permitted to have personal check cashing privileges, marker privileges, front money deposit privileges, cash advances processed at the casino and/or poker cages, use of safety deposit boxes at the casino and/or poker cages, as well as not being permitted to receive (i) gaming related direct mail marketing; (ii) gaming related telemarketing; (iii) gaming related promotional mail; and (iv) all gaming and non-gaming related customer recognition programs at all of the following MGM Resorts International properties ARIA, Beau Rivage-Biloxi, Mississippi, Bellagio, Circus Circus, Excalibur, Gold Strike Casino-Tunica, Mississippi, Luxor, Mandalay Bay, MGM Grand Detroit, MGM Grand Las Vegas, The Mirage, Monte Carlo, New York New York, and Slots-A-Fun. I understand that the States of Michigan and Mississippi have their own laws governing self-exclusion or disassociated patrons. These States’ laws require that persons wishing to avail themselves of the protection afforded under those laws to complete their state’s forms which can be requested by signing where indicated below. However, we will limit the casino and gaming related privileges available to you at our properties in Michigan and Mississippi. 2. I understand and agree that no further points, rewards, tier credits or any other benefits may be earned from any customer recognition programs in which I have participated. I further understand and agree that by requesting to be self-limited any points, rewards, tier credits or any other benefits I previously have earned from any MGM Resorts International customer recognition programs will be forfeited, included but not limited to any Express Comps or tier credits. I also understand and agree that MGM Resorts International shall continue to honor my request to self-limit my access to the gaming and non-gaming related privileges described above unless and until I request to rescind the voluntary self-limitation. I understand and agree that my request to rescind must be in a notarized writing; in a form approved by MGM Resorts International and that I shall not be allowed to make such a reinstatement request earlier than one year after the effective date of the self-limitation request. The States of Michigan and Mississippi have different rules regarding reinstatement which MGM Resorts International will honor at all properties. 3. I have been advised and agree that if I receive check cashing/marker privileges or gaming related (i) direct mail marketing, or (ii) telemarketing information, or (iii) promotional materials after the effective date of self-limitation, I will contact the Self Limit Compliance Officer at 702-590-2888, within ten (10) days of receipt of such information or materials. If I have questions concerning this Policy, I will contact the Self Limit Compliance Officer at 702-590-2888. I acknowledge that for my request of self-limitation to be truly effective, I must exercise self-restraint and I should not ask any MGM Resorts International employee to provide me with any of the services or privileges, which are the subject of this request. I agree this self-limitation request does not release me from any debts incurred prior to, or after, the effective date of this self-limitation request. I hereby release and hold MGM Resorts International harmless from any claim by me or any third party arising from my presence, acts or omissions upon the premises of any MGM Resorts International properties which occur after the effective date of self-limitation. I further agree that this self-limitation request does not obligate MGM Resorts International properties to return any funds wagered by me prior to, or after, the effective date of this self-limitation request. Signature: Date: I also request self-limit information for the state of Mississippi where we have Beau Rivage Biloxi and Gold Strike Tunica be sent tomy mailing address _____ e-mail address_____. Signature: Date: (Revised December 21, 2015) Page 1 of 2 I also request the self-limit form for MGM Grand Detroit to be sent to my mailing address _____ e-mail address_____. Signature: Date: I also understand that MGM Resorts International has a business relationship with Grand Victoria in Elgin, Illinois, , Borgata, Atlantic City, New Jersey, and MGM Grand Macau in Macau. Therefore, if I want to be self-limited at those properties I must contact them directly at the following addresses: Grand Victoria Casino For Borgata: MGM Grand Macau Attn: Security Department New Jersey Division of Attn: Legal Department 250 South Grove Avenue Gaming Enforcement Macau SAR, China Elgin, IL 60120 Arcade Building Tennessee Ave. and Boardwalk Atlantic City, N.J 08401 (609) 441-3846 This request cannot be processed without the completion of the information below. PLEASE PRINT NEATLY. Requests can be either mailed to: Legal Department, Mirage, 3400 Las Vegas Blvd. South, Las Vegas, Nevada 89109 or emailed to self- [email protected]. Full Name: Aliases / Nicknames Used: Date of Birth: Mailing Address: E-mail address Area Code/Telephone Number: ( ) Driver’s License Number: # State: Expiration: Social Security Number MGM Resorts International Casinos frequented Customer number at each casino MGM Resorts International endorses Responsible Gaming. If you or anyone you know may have a problem gaming responsibly, please call 1-800-522-4700 (Revised December 21, 2015) Page 2 of 2 .