Member's Afidavit of Good Character
***SAMPLE***
MEMBERS' AFFIDAVIT
OF GOOD MORAL CHARACTER
The undersigned, each for himself or herself, does hereby declare, subject to the penalties for perjury and
related offenses under Article 210 of the Penal Law of New York State as follows:
1. That he or she is a member of (name of organization and identification number) and has
been a member in good standing of such organization for at least one year immediately prior to the date
hereof.
2. That he or she is not an owner, co-owner, or lessee of the premises where the aforementioned organization
intends to conduct Bingo, or if said premises are owned by a corporation, that the undersigned is not an
officer, director or a stockholder thereof owning more than ten per cent (10%) of the outstanding stock.
3. That the undersigned is familiar with the provisions of the laws of the State of New York and the
(name of municipality) and the N.Y. State regulations pertaining to the
conduct of Games of Chance and/or Bingo.
4. The undersigned does hereby declare that he or she is a person of good moral character and has never been
convicted of a crime.
5. That the undersigned will not receive, directly or indirectly, any commission, salary, compensation, reward
or recompense for holding, operating, conducting or assisting in the holding, operating or conducting of the
Games of Chance and/or Bingo, nor has the undersigned been promised any such commission, salary,
compensation, reward or recompense except that if any of the undersigned are bookkeepers or accountants
who assist by rendering professional services as such bookkeeper or accountant, a total amount not
exceeding the amounts provided by the Rules and Regulations of the New York State Racing and Wagering
Board is to be paid.
6. Deponent makes this affidavit knowing that the (name of municipality)
relies upon the truth herein in issuing the license to the above-named organization.
ORIGINAL SIGNATURE
RESIDENCE
If necessary, use additional sheet of paper for members' names and residences.