GC6
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GC-6
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 TO AMEND
(pLEASE CHECK)
GAMES OF CHANCED
BELL JAR D
RAFFLE D
--,
Must be conspicuously displayed along with License.(GC-S)
(FOR OFFICE USEONL Y)
I /
Date
$/
Fee Received
(only if applicable)
GC-,[D- ITIJ- ITIJ- CIIIIJ
N.Y.S. Identification Number Present License Number
INSTRUCTIONS: PLEASE FILE THREE SIGNED COPIES WITH MUNICIPALITY
Street Address Municipality
Address where games are to be conducted:
County
Zip
Street Address Municipality
County
Zip
Application is'hereby made to amend the above numbered license. The amended information is contained in the schedules which are
checked below and attached, and are to replace the schedules previously filed.
D Schedule I.
D Schedule 2.
D Schedule 3.
D Schedule 4.
D Schedule S.
D Schedule 6.
D Schedule 7.
Officers And Directors
Members In Charge Of Games
Auxiliary/Affiliate Organizations Assisting At Games
Assistants To Members In Charge Of Games
Dates, Hours And Rent Of All License Periods To Be Held
Expenses
Types of Games
If any other information furnished on original application is to be changed, show amended data below.
L BJ-GC-6 (Rev. 4103)
Page 1 of2
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-,
I swear (or affinn):
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 Ru1es 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 responsible for the holding, operation and conduct of all games of chance in accordance with the tenns
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 N.Y.S. Racing and Wagering Board:
[D/OJ/OJ
Date Signature of the Head of Organization
Print Name
STATE
OF
NEW YORK
}ss
COUNTY
OF
CITY/fOWNNILLAGE
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
To be completed by Municipal Clerk:
Issued by
(Name of Municipality)
(Title of Authorized Officer)
(Signature of Authorized Officer)
(Date)
L BJ-GC-6 (Rev. 4/03)
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