GC2
I
"GC-2
-,
NYS RACING & WAGERING BOARD
1 Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
APPLICATION FOR:
PLEASE CHECK
GAMES OF CHANCED
BELL JAR 0
RAFFLE 0
FOR OFFICE
USE ONLY
$1 I ITJ/ITJ/IT]
Fees Received Date
INSTRUCTIONS: PLEASE FILE THREE SIGNED COPillS WITH MUNICIPALITY
GC - IT] - UTI- ITIJ - OIIIJ
N.Y.S. Identification Number
IT IS A MISDEMEANOR TO MAKE ANY FALSE STATEMENTS IN THIS APPLICATION
County
Name of Municipality
2. Address
3. Has applicant ever been denied a games of chance license? 0 Yes 0 No If "yes", why? (Attach extra sheet if necessary)
4. Check type of organization and, if applicable, give the State and date of incorporation.
Corporation 0
O State incorporated
Incorporated Association
Date IT] / IT] / IT]
Date IT] / IT] / IT]
Unincorporated Association 0
State incorporated
Individual
o
5. Did your corporate status change since your identification number was assigned? 0 Yes 0 No
6. Are you doing business under a trade name? 0 Yes 0 No If "yes", what is the trade name?
PART B. LOCATION OF GAMES
7. Address where games, bell jar, or raffle drawing(s) are to be conducted.
8. Name and address of authorized games of
chance lessor renting to applicant.
9. Does the applicant own the premises? 0 Yes 0 No If "yes", how long?
10. Capacity for public assembly of premises presently owned or occupied.
11. Have premises been regularly used? 0 Yes 0 No If "yes", how long?
Are games of chance being played now on these premises or has it ever been? 0 Yes 0 No If "yes", give full details.
12. Are the premises or any part thereof
where games of chance are to be played
licensed by the State Liquor Authority?
DYes
ONo
If "yes", state the type of license and number.
13. Has such license ever been
revoked or suspended? 0 Yes
ONo
If "yes", why? (Explain on a separate sheet, if necessary, and attach.)
L BJ-GC-2 (Rev. 4/03)
Page 1 of 2
11111I111I11111111I1111111111 .-J
-,
PART C. PURPOSES OF GAMES
14. State the specific purposes for which the entire net proceeds are to be devoted and in what manner.
I swear (or affirm):
1. That AlL the attached Schedules are a material part hereof and are incorporated herein as if set out in full in the application. All the answers
contained in this application are a material part hereof.
2. That the entire net proceeds of all games of chance shall be devoted exclusively to one or more of the "lawful purposes" as defined in the Games of
Chance Licensing Law and the Rules and Regulations of the Board.
3. That for each license period for which a license is sought, one or more of the active members under whose supervision the games are to be held,
operated and conducted, who is familiar with the Games of Chance Licensing Law, the Rules and Regulations of the N.Y.S. Racing & Wagering
Board and local licensing ordinances or laws, will be present at all times, in charge and primarily responsible for the conduct of games.
4. That the undersigned will be ~sponsible for the holding, operation and conduct of all games of chance in accordance with the terms of the license,
the provisions of the Games of Chance Licensing Law, the Rules and Regulations of the N.Y.S. Racing & Wagering Board and with the provisions
of local licensing ordinances or laws.
5. That the undersigned has read and is familiar with the provisions of the Games of Chance Licensing Law as amended, the Rules. and Regulations
of the N.Y.S. Racing & Wagering Board, and the local licensing ordinances or laws.
6. That no commission, salary, compensation, reward or recompense will be paid to any person for holding or assisting in the operating or
conducting of the games, except to bookkeepers or accountants for professional services in an amount not exceeding that fixed by the Board.
IT] / IT] / IT]
Date Signature of Head of Organization
Print Name
STATE
OF
NEW YORK
}ss
COUNTY
OF
CITYrrOWN/VILLAGE
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
L BJ-GC-2 (Rev. 4/03)
Page 2 of2
11111111111111111111111111111 .J