BJ1A
r
lA
NYS RACING & W AGBRING BOARD
I Watervliet Ave. Bxt., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
Check the type of program(s) you are applying for: 0 Bell Jars
Check appropriate box: 0 New 0 Update 0 Assisting Only
APPLICATION FOR
REGISTRATION AND
IDENTIFICATION NUMBER
I
o Casino Night
o Raffles
o Bingo
1. Name of applicant organization
Date of Application: CD / rn / rn
2. Physical street address of organization (cannot be a PO Box):
City
Zip
Street Address
3. Mailing Address if different than above (may be a PO Box):
Street AddressIPO Box
City
State
Zip
4. Municipality where the organization is physically located or where the organization meets:
CITY / TOWN / VILLAGE
(PLEASE CIRCLE ONE)
of
Name of Municipality
County in which the organization is located:
5. Date the applicant organization was formally Organized:CD / CD / CD
Note: an organization must be in existence for a minimum of three years prior to applying for games of
chance and one year for bingo
6. Has a games of chance identification number ever been issued to the applicant organization? 0 Yes 0 No
If yes, list the ID#: rn - rr=o - rr=o - ITIIIJ
7. Has a bingo identification number ever been issued to the applicant organization? 0 Yes 0 No
Ifyes,listtheID#:rn - rr=o - rr=o - ITIIIJ
8. State the type of the organization (religious, educational, veterans, etc.):
9. Has the applicant ever been known by another name? 0 Yes 0 No
If yes, state name and address:
Street Address
City
State
Name
Zip
10. Is the organization incorporated? 0 Yes 0 No
11. Does the applicant have a governing body (Le. Board of Directors)? 0 Yes 0 No
If yes, how many members are there in that governing body?
12. State current number of bona-fide members of the applicant excluding the governing body:
NOTE: A person must be a bona-fide member of the organization for a minimum of one year in order to be
involved in the conduct of licensed games of chance,
13. Please give time and address of regular membership meetings:
Address
Time
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14. Does the applicant organization own or lease its premise? (circle one)
~ / LEASE
15. Will the applicant organization conduct games of chance DYes D No and/or bingo DYes D No
on its own premises? D Yes D No If not, list-the name and address of the premises to be used:
Zip
Name
Street Address
City
State
~: An organization is limited to the location where games of chanceJbingo can be conducted.
Please review the games of chance/bingo rules and regulations regarding authorized locations
avaUable on our website at www.racin2.state.nv.us
16. Please list the name of the licensed games of chancelbingo supplier where the organization intends to purchasellease its equipment
from:
NOTE: This does not include raffle tickets.
ATTACH ONE COpy OF EACH OF THE FOLLOWING:
I _ If incorporated: provide a copy of the articles of incorporation and by-laws;
If not incorporated: provide a copy of the constitution and by-laws;
2 - If the organization has a charter, please include a copy;
3 _ Please provide a list of the names and addresses of the members of the governing body including titles.
] swear (or arrmn) that the information and statements contained herein have been examined by me and to the best of my
knowledge and belief are true, correct and complete.
Head of the Organization Home Mailing Address
Head of the Organization Signature
Head of the Organization Home Phone Number
Head of the Organization Print
STATE
OF
NEW YORK
}ss
COUNTY
OF
CITyrrOWNNILLAGE
OF
being duly sworn deposes and says that (s)he is the person above named,
that (s)he has read the foregoing statement and the answer therein noted, and that such answers are true and that (s)he has personally
affixed his (her) signature to this affidavit.
Sworn to before me this
day of
,20_
Signed
Commissioner of Deeds
Notary Public
My Commission expires
, 20
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