GC2A
I
, GC-2A
I
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 GAMES OF CHANCE LICENSE
Name of Organization
GC- [D - ITIJ - OJ] - ITIIJJ
NYS Identification Number
SCHEDULE 1: OmCERS AND DIRECTORS
List names. addresses and dates of birth of all officers.
If organization is a corporation, or an incorporated or unincorporated association. list officers and directors.
TITLE NAME DATE OF BIRTH STREET ADDRESS
I 1_1_1_'
1 1_1_1_1
1 1_1_1_1
I 1_1_1_1
I I~/_I_I
i I_I_/~I
I 1_1_1_1
I 1_1_1_1
I 1_1_1_1
I 1_1_1_1
I 1_1_1_1
Attach additional sheet if necessary.
[D/[D/[D
Date
CITY
ZIP
NAME
MEMBERS IN CHARGE OF GAMES
(MUST LIST AT LEAST FOUR MEMBERS OF APPUCANT ORGANIZATION)
DATE YEARS OF
, OF BIRTH MEMBERSHIP STREET ADDRESS
1_1_1_1 1
1_1_1_' I
1_1_1_1 I
I_/~/_I 1
1_1_1_1 I
1_1_1_1 I
'---1_1_1 I
1_1_1---1 I
1_1_1_1 1
CITY
ZIP
SCHEDULE 2:
SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF 2 AUXILIARIES/AFFILIATES. EACH AUXILIARY/ AFFILIATE LISTED MUST HA VB ITS OWN ID NUMBER.)
NAME OF AUXILIARY/ AFFll.JA TE
GAMES OF CHANCE ID NUMBER
L BJ-GC-2A (Rev. 4/03)
Page 1 of2
1/111111111111111111111111111 --.J
r SCHEDULE 4: ASSISTANTS TO MEMBERS IN CHARGE OF GAMES
List all members of applicant organization and members of authorized affiliates and auxiliary who will assist with games. Each person listed must be a
member of applicant orwmization or affiliate for at least 1 year.
YEARS OF
MEMBER NAME . DA1E OF BIRTH MEMBERSIDP STREET ADDRESS
I I I I_I
1-1-1-1_1
1=1=1= I _ I
1_1_1_1-
1_1_1_1-
1_1_1_1-
I I I 1-
1-1-1-1-
1-1-1-1-
1=1=1= I _
1_1_1_1-
1_1_1_1-
1_1_1-
1_1_1-
i_I _I_
I_I _1_
1_1_1- _I
I_I _I_
I_I _1_
1_1_1-
i_I _I_
I_I _I_
I_I _I_
I I. I
1=1=1 _
I_I _I_
I_I _I_
I I I .
'=1=1=
1_1_1- _I
1_1_1- _I
1_1_1- _I
1--1_1- _I
1_/_1_ _I
L BJ.GC.2A (Rev. 4/03)
Attach additional sheet if necessary.
Page 2 of 2
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