Send completed application to IMGL Membership Chair:

Michael E. Zatezalo
Managing Partner/Director
Kegler, Brown, Hill & Ritter Co., L.P.A.
65 East State Street, Suite 1800
Columbus, OH 43215-4295
Tel:(614) 462 5400
Fax:(614) 464 2634
E-mail:  mzatezalo@keglerbrown.com

Name __________________________________

Title____________________________________

Birth Date:________________

Firm or Organization _______________________

Address __________________________________

Address __________________________________

City________________State/Province___________

Postal Code_____________Country_____________

Tel:__________________Fax:_________________

E-mail:___________________________________

Cell No:__________________________

Type of membership applied for:

( ) General Member
( ) Affiliated Member-Accountant
( ) Affiliated Member-Consultant
( ) Affiliated Member-Counsel
( ) Affiliated Member-Educator
( ) Affiliated Member-Regulator
( ) Affiliated Member-Young Gaming Attorney

1. Describe your position with the firm or
organization:

_________________________________________

_________________________________________

_________________________________________

2. How long have you been associated with/employed by this firm/organization? (If less than five year, please list your former relationships and positions on a separate sheet.)

_________________________________________

3. If you are an attorney, accountant, or other licensed professional, when were you called to the Bar or admitted to your Professional Body?

_________________________________________

4. Are you a member in good standing of the Bar or your Professional Body?

_________________________________________

5. How long have you been involved in the gaming industry or practicing gaming law?

_________________________________________

6. List all gaming clients, contact persons and the nature of work that you undertake for them (provide details on as separate sheet. If client confidentiality demands otherwise, please so notify the Membership Committee).

7. Have you participated in any educational seminars relating to gaming and if so, in what capacity (Provide details on a separate sheet if needed.)

_________________________________________

8. Have you written any articles/books/treatises relating to gaming? (provide details on a separate sheet if needed.)

_________________________________________

_________________________________________

9. Have you participated in any philanthropic or charitable programs relating to gaming and if so, in what capacity? (Provide details on a separate sheet if needed.)
_________________________________________

10. Describe briefly why you desire to be a member of the IMGL and what contributions do you believe you can make to the association? (Provide details on a separate sheet if needed.)

_________________________________________

_________________________________________

11. Name of IMGL member who is sponsoring this application.
Sponsor:

_________________________________

Date:______________________________


Signature:_________________________________