Wappinger Elks Lodge #2609
I"
GC-2
--,
APPLICATION FOR:
PLEASE CHECK
GAMES OF CHANCE uY"
BELL JAR D
RAFFLE 0
$1;;5.';.'-' I
Fees Received
NYS RACING & WAGERING BOARD
I Watervliet Ave. Ext., Suite 2
Albany, NY 12206.1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
FOR OFFICE
USE ONLY
[ill] i -rd. i.~ I / rn
Dale
INSTRUCTIONS: PLEASE FILE THREE SIGNED COPIES WITH MUNICIPALITY
GC - []]Kl- [i[[IS]-llJillJ - ~
N.Y.S. Identification Number
~A MIS!,EMEANOR TO MAKE ANY FALSE STATEMENTS IN THIS APPLICATION
Fi fPLU~((< JJUTC J-I/Es:.S
Name 0 Municipality , County
PART A. GENERAL
1. Name of Or anization
2.
3. Has applicant ever been denied a games of chance license? 0 Yes XNO 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
Incorporated Association }(' State incorporated
Unincorporated Association 0
State incorporated
Individual 0
5. Did your corporate status change since your identification nU~ber was assigned? DYes 0 No
6. Are you doing business under a trade name? 0 Yes ~o If "yes", what is the trade name?
PARTB. LOCATION OF GAMES
7. Address where games, bell jar, orraffledrawing(s) are to be conducted. .1.116' Rio 3 U WR PPltJ&ff? ' l'iY.
8. Name and address of authorized games of \. I J n
chance lessor renting to applicant. -Nf-O
9. Does the applicant own the premises? l(Yes 0 No If "yes", how long'!
Date [O]]J / ~ / CW
Date rn / rn / CD
10. Capacity for public assembly of premises presently owned or occupied.
11. Have premises been regularly used? ~es 0 No If "yes", how long?
Are games of chance being played now on these premises or has it ever been?
~lt. ~OtJ'1
5
\ 2. Are the premises or any part thereof ~
where games of chance are to be played AYes
licensed by the State Liquor Authority?
13. Has such license ever been \ /
revoked or suspended? 0 Yes !JJ No
DNa
If "yes". slate Ihe type of license and number.
e~LlI3. CLOl1014'JvN3
If "yes", why? (Explain on a separate sheet. if necessary, and attach.)
L BJ-GC-2 (Kev. 4/03)
Page I of2
1111111111 \\1\ 1111I1111111111 .J
r
I
PART C. PUKl'OSES OF t~i\l\'lES
14 .\:;11':. lh.: spc-:ifll: pmposes fot which the l'.lltire Ill'.l pIlH.:et:ds ,ue In be deYOle-1.! alld ill WhUlIlHIIIIICr.
I 1/3 < ~ 1.3 0 peR 1\ -(, 0 N S
r- I
I 'i",,'oJ IUI ,dlirtlll'
Thai AU.. ltle ;.!1l,lCl1ell Sl'l\t;(iuks an: il lIHlIeriill pmlhe.rl:nl'lllld ill" in~oqJ\)nll~d Il<:rcill as if s~l UIllln full in the upplicilllUll. All the ailSWCr\
;'.lI\l~lIled IH lhis uppli":ctlilHl ure.. il Jllmcrial PWl h\:reul.
ThUlin,; "HIIIL' !leI pruceeds uf all game, 1)1' dHIllce shull b~ dt:\'ot~ I.'>xclll$i ycly to (lm: llr more elf the "lawful purposes" as L1el1neLl in [he Gamt$ vi'
Challl'~ Ul'c!lsin8 Law WILl 111e:: I:{LI!c.S and Regulations of Ihe Helurd,
nM ILlr cadI Ikcml: pcri<.>d lor which a license is soughl, ont. or more of llle a(;li\'e melllb<;;rs ulIdt:J whose Sllperyision the games are to be held.
\lVCr,lleJ and cLlwJu..:tcd, whLl is familiar with lh~ GUll11:S of Chuncl.'> Lict;:nsing Law, the Houles and \{egulations of the N. Y .S, Racing &. Wagerlllg
Huurd I1I1J lo(:"lliceJ\sill~ vrdinunc<:.> or laws, willl1e Ilrt~Senl ill alllillle:S, in charge: ulld primmil)' re~llolIsiLJlc fllr l.he conducl of gamcs.
:'
4.
I'IIU\ llle Ilnlll.'>rs\gn~Ll Will t1\:' n:spulIsibl"" I'lli' the holding, lIpelllliollllllLl CllnLluc:luf ull gallles uf d\iUICC in uccl)rdun~'c with lhe ICUlIS of the licclIs~.
the [JI lI\l.\iuns uf Ihe Gil,lJ\CS vI' Chalice Licensing Law, 1Il<.: RlIll.'>s und R\lgulalions of the N, Y .S, Racillg <'11. Wagering Buard and with the prllYlsiol1s
uf I'll'il, licensing on.!i nunL'es or I"ws.
:-.
Tt!UI IIle uIl1.krsq;ned hilS read and b fumiliar with tile prllvisiollS of Ihe Clilllles or Cllanl:e l,il:tllsing Law as illllt:nded, the Rules und RegulatiollS
ul 1I1~ !"Y,S. RUcing & Wagering BOi.ln.!, uno the locul licensing onlllllUlces or luws,
6,
ThuIII" L'.UlIlIlIiss;I)n, saltl"Y, ClllllpCnSUli()n, rewurd or recompense will he p~lid to any persoll for holdinlllll assisting 111 the operutlng or
l'dlldUL'lIl1g l\t' 1I1c gunl<:s, exec'PI III buokkeepers or accollntants I'or pmi'essionul services in all alllOllllllllJI e,~I:c:edillg thai thed by thc Board.
[Q]iJ / [2Ji] / ~1i1 ~----
I late SJgnalllr~ 01 Head u[ OrgHllll,HlIU1\
)) I!(-\~ I t: 1<
Prin\. Nume
Ml11 ~--
or NEW YORK
UF'~LJ,C\\e~-$ ." }ss
Ob WAf'(7I.IlG-E.& f~,\lS
._ Vy\ J. '
..,.....:2.,.-f!::_: v-:..'~ ck:-.__ .- \ l S bdng duly' SW(lfll deposes anu says that (s)lIe is the person above lHuned,
lhal I 'ilk ki.-; iellll lhe forcgl!ing sllllelllcnt and lbe answel: therein noted, aud that such answers an~ true and mat (s)he has personally
;i1l1.,<,-IIH', (hen sigllalllre to tllis anid"vl.\.
SI:\11::
CUUNTY
CiTY iTOWNIVILLAUr::
Swum to beLlI': Ille; Ihls 5
daY.lf
:fu-L;
,20~
Sign~'t1
r?~~ )~.~-
Commissioner of Deeds
N.ll;ll)' Public
tvl)' CUlIillIISS;\ln cx.pilcs
20
PHILLIS J. SIMONE
Notary Public, State of New Yorl<
No.01S15030420
Qualified in Dutchess County
Commission Expires July 18. 20.J2.
L lIJ.LC.2 \I{c" 4,U,l,
l\\ge '2 \),'2
III \ 111I\111 II \\11I11 III II 11\ .J
\
APPLICATION ]i'OR GAMb~S OF
CHANCE LICENSE
.2B
c ' I I' " ami pm - ' am I pIn
__ _____ _~ c_~-' ------" ~~' ~
I Ii' am I pm - am I pin
~-' ----- ~~' ----~'~ ~'~
I I \ ' am/l.nIl o. . am 1\)111
~ -' -"' ,-~~' ~ ----"-.--'
I I I ' amiI'm -- ' amiI'm
~ ~ "-----,' ~~'~ ~'~~
I I \ ' am I pIll - : ami pm
~i)~ =-=' "-"~'~ m(1'EN~ ~~
List itemS of expense to be incurred, and the nanies ,nd addresses of persons to be pald-
yfEM Of EXPENSE VENDOR NAME STREET ADDRESS errY ST ATE Z.IP
~ l(~E1itr!;lDcy~le~~V:iJ)S;~
Ll~~v~~f~~)-S
_....--~.------_...,-------
---------- --------- ------- -- -
------ ---- ------- ---
------------ ------------ ---- -- ---
\\\~\ \ \\\\\m\\\\\l U .J
----------
--------
L 1\,j_GC-).6 (Rev. 410;')
Page \ or '2.
SCllEDULE 7 TYPES OF GAMES 1
List all of the single types of games to be conducted al a1Ilicense periodS enumeraled in Schedule 5.
Note for Ve as I'll blS and Bazaars onl : The total amount of ptiz.es during anyone license period shaU nol
aggtegate more than $400 for each single Iype of game of chance when !i3 lypeS of games of chance are to be
conducted during anyone license period. The total amount of priz.es during anyone license period shall not
aggregate more than $500 for each single type of gameS of chance when ~s than fi3 single types of games of
chalice are to be conducted during anyone license period.
LIST NAME OF EACH TYPE OF
GAME OF CHANCE
(Limit: 5 Games)
Dl~ c ~ -::[f) C k..
:ro~it /ol-ItIL
__ 13; 6 5,.1- W IIf l L
at
-
~ :t
=- at
at
~
For Merchandise Wheels. BeUlars and Rafl\es. please complete me appropriate spaces beloW.
MERCHANDISE WHEELS:
INDICATE NUMBER OF
MERCHANDISE WHEELS
(NO uMTD
THE TOTAL AMOUNT OF pRJZES FOR
EACH MERCHANDISE WHEEL sHALL
NOT EXCEED $10,000 AND NO SINGLE
pRIZE SHALL EXCEED $250
BELL] AR:
nre TOTAL AMoUNT OF PAYOUTS
FOR EACH BELL JAR DEAL SHALL NOT
EXCEED $3,000 AND NO SINGLE PRlZE
sflALL EXCEED $500
INDICATE IF THIS APPLlCA nON
IS FOR A BEU-. JAR
LICENSE
yES 0 NO "f.
RAfFLES :
INDICATE IF TIUS APPLICATION
IS FOR A RAFfLE
LICENSE
yESO NO ~
IF YES, LlSTRAFfLE DATES, TlME(S)
OF DRA WlNG(S) AND pRlZES IN
SCHEDULE 5
THE TOT AL AMOUNT OF pRlZES FOR
ALL THE RAFfLES CONDUcrED DUR-
ING TlUS cALENDAR YEAR SHALL
NOT EXcEED $100,000. NO SINGLE
pRIZE sHALL EXCEED $50,000
EXCEPT THAT A SINGLE pRIZE OF
$100,000 MAY BE AWARDED IF SO
INDICATED IN ScHEDULE 5
UII\I\lIM\I\\\\I\ .J
Page 2 of2
L BJ.GC-'lB (llcv. 41(3)
-'
:;C-2A APPLICATION FOR GAMES OF CHANCE LICENSE
-lYS RACING & WAGERING BOARD
I Watervliet A'Ie. Ext.. Suite 2
i\1bany. NY 12206-1668 '
1'o1",hon0(518) 453.8460 FM (518) 453.8492 ,,"- .
WW'_~ 't' ,., ,.., \..''''~' '\..'U '\J'U-"~ ~
~
GC- \ill1-LJIill1- [Hill] - ~ [QIj I @] I @1]
NYS Identification Number Date
SCHEDULE 1: OFFICERS AND DIRECTORS
Ust names. addresses and dates of blnh of all officers.
If organization is a corporation. or an incof1lorated or unincorporated association. Ii~t officers and directors.
TITLE NAME..--A, .. '" ... DATE Q{ BIRTH STREET ADDRESS CITY
IClj,1t~ ~l~~'t.LI_1 1
\ 1_1_1_1 I
I 1_1_1_1 1
1 1_1_1_1 1
1 1_1_1_1 I
1 1_1_1_1 I
1 1_1_1_1 I
1 1_1_1_1 1
I 1_1_1_1 1
I 1_1_1_1 1
\ I_I ~b_1 1
Attach additional sheet if necessary.
MEMffiERSINCHlRGEOFGAMES
(MUST LIST AT LEAST fOUR MEMBERS Of APPLlC~T ORGANIZATION)
DATE YEARS OF
NAME OF BIRTH MEMBERSHIP sTREET ADDRESS CITY ZIP
?rIv '-- B ft.at.~~ 1l5L I Co '5l jL 1 \ ~ M'9R~Wt:> R() ) !:B:fM-V~IrIt.J-t\<:, ,~ l{ 1l
~\(.t\-- Oo(J,f'>l vi> 5' I :!& I ~I ~ 11> ':;'lfyl'; ~ \.) R. I':0'rPV.~ \ 1)- &'t '"
'" l \,(0 '" l~ 'S I .1l?-1 ~I =-.1:-1 't ~1f11I- 1/\6-'" u.., ~ \tl!: ..J' 11:....:\ t!t', \ \ 1--~; 17
I.-ll;.1 l,Hllil1'\ 1 J I .EL1.fz-1 .., I?-'i' lll~ lIt.JU! I.lf < IU All/' .....A.l.-l. '7i l)- $"' q-o
1_1_1_1 1 \ I
1_1_1_1 1 1 1
1_1_1_1 \ 1 1
1_1_1_1 1 \ 1
1_1_1_1 \ \ 1
ZIP
SCHEDULE 2:
SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASsISTING AT GAMES
(MAXIMUM OF 2 AUXlLlARIESIAFFD-IATES. EACH AUXlLlARY/AFFlL1ATE LISTED MUST HAVE ITS OWN ID NUMBER.)
NAME OF AU~Y/AFFJLlATE GAMES OF CHANCE ID NUMBER
L .,~:'A1R"'''''' . . - Page 1 012 ~IIIIIIU~'mUI .J
- '
SCHEDULE 4: ASSISTANTS TO MEMBERS IN CHARGE OF GAMES
U. .11 ~mba' of 0,,1i'~' "..,i""i~ ~d m="" of .",hori~d "'il"'~ ~d ...m., .... ."...., .ilh .-. Eooh "'~ Ii"", m~' "'.
member of appliClU\1 or!1;anizAlion or affiliate for alleust I year.
YEARS OF
.1EMBER NAME . DATE OF BIRTH MEMBERSHIP STREET ADDRESS
\_/_/_\ _\
~~ 1_1_1_1_1
r?t-~~\_/ _/ - \ - \
1>-\ ~ '} \ / / \ \
\=/=/= \ = \
\_/_/- \ - \
\_/_/- \ - \
\_/_/- \ - \
\~/_/- \ - \
\_/_/- \ - \
\_/_/- \ - \
\_/_/_\ _\
\_/_/- \ - \
\_/_/- \ - \
\_/_/- \ - \
\_/--/-- \ - \
\_/__/- \ - \
\_/_/- \ - \
\ / / \ \' -,''''
\=j=j= \ = \;i
\=/=/= \ = \
\--/_/- \ - \
\_/_/- \ - \
\_/_/- \ - \
\_/_/_\ _\
\_/_/_\ _\
\ / I \ - \
\-/-/- \
--- _\
\_/_/- \ - \
\_/_/- \ - \
\_/_/- \ - \
\_/_/- \ - \
\_/_/- \ - \
CiTY
ZiP
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\\\\\\l\\U\ \\\1\ \\U\ I \\\\ l\ -'
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
L IlJ.GC.2A (Rev. 4103)
Attach additional sheet if necessary,
Page 2 of 2
Schedule 4. Assistants to Members in Charge of Games
Years
First MI Last Name Address Town Elk DOB
Frank Abato 39 Kensington Drive Hopewell Jct 11 04/24/1940
Philip A. Abbate 6 Hackensack Hghts Rd Wappingers Falls 18 05/16/1937
Robert Acquanita 10 Vorndran Drive Wappingers Falls 22 OS/25/1942
Ralph J. Anzivina 12 Thorns Lane Highland 22 12/21/1935
Henry J. Boldrin 28 Gold Road Wappinger Falls 15 01/11/1936
Harold A. Crawford Sr. 318 Sunset Hill East Fishkill 18 02/23/1936
Francis J. DeGano 27 Brandy Lane Wappingers Falls 18 07/18/1946
Roger DeJordy 83 Kent Road Wappingers Falls 18 09/19/1944
Richard O. Desruisseau 183 Red Cardinal Court Poughkeepsie 21 11/05/1936
Richard D. Dobbins 6 Schuele Drive Wappingers Falls 22 05/30/1949
Stephen F. Drobnak 53 Moccasin View Rd. Fishkill 9 02/02/1957
Robert Fischetti 91 Ardmore Drive Wapplngers Falls 28 06/07/1926
Mark H. Fox 28 Tiger Road Hopewell Jct. 14 09/15/1957
Harris C. Jones 217 Brothers Road Stormville 18 04/24/1944
Robert J. Juliano 2776 West Main Street Wappingers Falls 13 10/05/1953
William K. Minkowski 427 McGrath Blvd. Fishkill 28 03/20/1942
Eugene P. Pampalone 53 Helen Drive Wappingers Falls 20 09/03/1936
Rosemarie Perretta 35 Cathy Road Poughkeepsie 8 09/07/1943
Gregory F. Sarno 13 Dana Place Wappingers Falls 28 07/01/1936
Kenneth J. Tucker 34 Pawling Lake Pawling 9 03119/2029
Robert N. Wallner 7 Kinry Road Poughkeepsie 19 01/17/1933
Schedule 1: Officers and Directors
WAPPINGER LODGE #2609 OFFICERS for 2007-2008
Title Name Address Town Zip DOB
.-.-....-------------- --------------- -------------------------- ------------------------------ -----...--...............-.... .
Exalted Ruler Derrick Mills Pawling Lake Box 17 Pawling 12564 10/10/1940
Leading Kgn Sandra Seekamp 67 Pawling Lake Pawling 12564 12/10/1945
LoyalKgn Mark H. Fox 28 Tiger Road Hopewell Jct. 12533 09/15/1957
Lect. Kgn Diana M. Cole P.O. Box 549 Hughsonville 12537 04125/1948
Esquire Rocco Valente 61 Fishkill Hook Rd. Hopewell Jct. 12533 06/06/1941
Chaplain Catherine Rohling 54 Brothers Road Wappinger Falls 12590 04/22/1940
Inner Guard Kenneth J. Tucker 27 David Lane Pawling 12564 03/19/1929
Secretary Robert M. Acquanita 10 Vorndran Dr. Wappinger Falls 12590 OS/25/1942
Treasurer Richard O. Desruisseau 183 Red Cardinal Court Poughkeepsie 12603 11/05/1936
Tiler Susan Dorler 21 Valley Road Wappinger Falls 12590 03/29/1939
Trustee James Boyer 134 Andrews Road Lagrangeville 12540 11/28/1937
Trustee AlanD. Schrock 85 Hillis Terrace Poughkeepsie 12603 02/23/1945
Trustee Joseph P. Havelka Sr. 13 Pawling Lake Pawling 12564 11/13/1942
Trustee Dana Mills Pawling Lake Box 17 Pawling 12564 02/18/1971
Trustee Charles V. Hertel 11 Terra Nova Dr. Hopewell Jct. 12533 09/27/1932
No Officer receives compensation of any kind.
r
GC-4
NYS RACING & WAGERING BOARD
] W~terv]jet Ave. Exl., Suite 2
Albany, NY ] 2206. ] 668
Telephone (5]8) 453.8460 Fax (518) 453.8492
. www.racing.state.ny.us
I
FINDINGS AND
DETERMINA TION
FOR GAMES OF CHAN'CE
LICENSE
GC-~-~-.GJill-~
N.Y.S. Identification Number
Town of Wappinger
Name of Municipality
W
Falls. New York 12,gO
A. fier investig. ation, and a hearing if required under Sec. 192 of the General Municipal Law, the following findings and dete:;t.na. ~s
have been made: .' . .
. -
1. All the members-in-charge designated in the application to conduct ga es of chance are of good moral - Yes D No
character and have never been convicted of a e. -
Signature of Person Conducting Investigation
Title
2. Applicant is a qualified authorized organization as defined in the Games of Chance Licensing Law.
3. All the members designated in the application to conduct games are bona fide active members of the applicant
organization.
4. The premises presently owned or occupied by the applicant are in every-respect adequate and suitable for
conducting games of chance.
5. The games of chance are to be conducted in accordance with the provisions of the Games of Chance Licensing
Law, the Rules and Regulations of the N.Y.S. Racing and Wagering Board, and local ordinances.
6. The entire net proceeds are to be devoted exclusively to one ore more of the "lawful purposes" as defined in the
Games of Chance Licensing Law and the Rules and Regulations of the N.Y.S. Racing and Wagering Board.
7. There is satisfactory proof that no commission, salary, compensation, reward or recompense will be paid or
given to any person for conducting the games or assisting therein, except to the extent authorized by the Garnes
of Chance Licensing Law and the Rules and Regulations of the N.Y.S. Racing and Wagering Board.
8. There is satisfactory proof that the type and value of prizes offered and given will be in accordance with the
provisions of the Games of Chance Licensing Law.
9. If applicable, the rent La be paid to an authorized games of chance lessor is reasonable.
10. Other findings: (Specify)
KI Yes DNo
KI Yes DNa
OCI Yes DNo
OCI Yes DNa
IKl Yes DNa
,OCI Yes DNo
WYes DNa
IlO Yes DNo
DYes DNo
TO BE COMPLETED BY MUNICIPAL CLERK: ,.,
As a result of the findings and determinations stated above, license is GRANTED g;1icense is
/ 1'\ _ I Signature of
Filing date of Application '1 ~ 0'" Authorized Officer
Date li'~ Titl, Town Clerk
ONE COPY OF THIS FORM TOGETHER WITH ONE COpy OF FORM GC-2, 2A, 2B MUST BE RECEIVED BY THE
N.Y.S. RACING AND WAGERING BOARD FIVE DAYS PRIOR TO THE FmST AUTHORIZED LICENSE PERIOD.
L DJ.{;C.4 (Rev. 4/03) 11111111111111111111111111111 .-J
I
GC-5
I
LICENSE TO CONDUCT
GAMES OF CHANCE
PLEASE CHECK
GAMES OF CHANCE DlI
BELL JAR 0
RAFFLE 0
GC - ClUJ - [ili]2J- GJil?J - ~
N.Y.S. Identification Number
NYS RACING & WAGERING BOARD
1 Broadway Center, Suite 600
Schenectady, NY 12305-2553
Telephone (518) 395-5400 Fax (518) 347-1469
www.racing.state.ny.us
This License Must Be
Conspicuously Displayed
During Conduct of Games
$1 25.00 II
Amount of Fee Paid Lessor's License Number
Address: 11 C)'j R011te 176 City: Wappingers Falls. NY
Entire net proceeds to be devoted to the following specific lawful purpose(s):
1/3 Charitable, 2/3 Operations
Names of Members in Charge
Rich Dobbins
Zip Code: 12590
Simon Kan fman
Lew Hakim
P:11I1 BRoer
LICENSE PERIOD
DATE
DAY OF WEEK
HOURS TYPE(S) OF GAMES
Au~ust 3. 2007
Friday
7:00 pm - 1:00 am Black Jack. Joker Poker.
Big Six Wheel
RAFFLE DRAWING
DATE
DRA WING TIME
DRA WING LOCATION
AMOUNT OF RAFFLE PRIZES (Cash or Merchandise Prizes
at Fair Market Value)
THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
FOR EACH TYPE OF GAME OF CHANCE
3 $ 500.00
NUMBER OF GAMES EACH GAME (Starting Bank)
THE TOTAL AMOUNT OF PRIZES FOR EACH BELL JAR
DEAL SHALL NOT EXCEED $3,000 AND NO SINGLE PRIZE
SHALL EXCEED $500.
THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
FOR EACH MERCHANDISE WHEEL
$
NUMBER OF WHEELS
EACH WHEEL
GAMES SHALL BE PLAYED IN ACCORDANCE WITH
ST ATE LAWS AND RULES AND LOCAL ORDINANCES OR
LAWS.
Issued by
~n~n nf W~rp;~T
(Name 0 unicipality)
re of Authorized Officer)
11111111111111111111111111111 -.J
August 3. 2007
(Date)
L BJ-GC-5 (Rev. 3/06)
r
GC-6
NYS RACING & WAGERING BOARD
1 Broadway Center, Suite 600
Schenectady, NY 12305-2553
Telephone (518) 395-5400 Fax (518) 347-1469
www.racing.state.ny.us
I
APPLICATION TO AMEND
(PLEASE CHECK) /
GAMES OF CHANCE (g'
BELL JAR 0
RAFFLE 0
,
~\
Must be conspicuously displayed along with License (GC-5)
.._'~_. .~.~._~~-
$1 a5.(J7) I 001 ~o71
Fee Received Date
(only ifapplicable)_____
GC-ITIIJ-[&ffiJ-~-IOIDtIOI/131 I ot-to5
N.Y.S. Identification Number Present License Number
INSTRUCTIONS: PLEASE FILE THREE SIGNED COPIES WITH MUNICIPALITY
(FOR OFFICE USE ONLY)
/;lS9v
/)i/7ChiSS
County
Zip
Street Address
Municipality
Zip
County
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.
o Schedule 1.
Officers And Dire.ctors
o Schedule 2. Members In Charge Of Games
o Schedule 3. Auxiliary/Affiliate OrganizationS Assi~ing At Games
o Schedule 4. Assistants To Members In Charge Of Games"
j(schedule 5. Dates, Hours And Rent Of All License Periods To Be Held
o Schedule 6. Expenses
o Schedule 7. Types of Games
If any other information furnished on original application is to be changed, show amended data below.
t ,;
L BJ-GC-6 (Rev. 3/06)
Page I of2
IHIIII~IIIIIIIIIIII ..J
I
GC-2B APPLICA nON FOR GAMES OF
NYS RACING & WAGERING BOARD CHANCE LICENSE
1 Broadway Center, Suite 600
Schenectady, NY 12305-2553
Telephone (518) 395-5400 Fax (518) 347-1469
www.racing.state.ny.us
-,
GC-[ill]- 0illJ-I~lol;zI-~
NYS Identification Number
[IJ/[IJ/[IJ
Date
SCHEDULE 5 DATES, HOURS AND RENT OF ALL LICENSE PERIODS TO BE HELD
(NOT APPliCABLE FOR BELL JAR GAMES)
DATE HOURS
. O. 6./ .0 . 3, / , c>. 7.! . () . 7 ,:. o. c> ,am /@- , 1. I ,:,5, q ,am /~! $ .
. . , I . . /. . .!. . , : . . ,am / pm -. . . : . . ,am / pm ! $ .
, I , , / , ,! , , . , ,am / pm - , . , ,am / pm ! $ ,
, / . , / . . I . , . . ,am / pm - . . . ,am / pm ! $ .
. / . , / . ,! . . . . ,am / pm - , . .am / pm ! $ .
, I , , / . .! . , . . ,am / pm - , . . ,am / pm ! $ .
, / . . I . , I . . . . ,am / pm - . . . ,am / pm ! $ .
, / . , I . .! . . . . .am / pm - , . . ,am / pm ! $ .
. / . . / . .! . .. .am / pm - , . . .am / pm ! $ .
/ . / , . I . , . . ,am / pm - . . . .am / pm ! $ .
, / , , / . ,! , , . . ,am / pm - , . , ,am / pm I $ ,
. / . . / . I .. . .am / pm - ... .am / pm ! $ .
RENT
,0,.,0.0,
1-'
.-,
I-'
I-'
,-,
0-'
I-'
,.
RAFFLES PRIZES (Cash or F air Market
DATE TIME
./ , ./ . I Value of Merchandise)
am / pm - am / pm !$. .., ...
. I . .-. 1-' ,
,/ . ,/ . I am /pm - am/pm !$.
. I . ,- . ,-, , ,-,
,/ . ,/ . I am / pm - am / pm !$.
. I . ,-. .-, . ,-,
,/ . ./ . I am / pm - am / pm !$.
. I . .*, I- . . .-,
./ ./ . I am / pm - am / pm !$.
. . I . .. . 1-' , 1-'
SCHEDULE 6 EXPENSES
List items of expense to be incurred, and the names and addresses of persons to be paid.
ITEM OF EXPENSE VENDOR NAME STREET ADDRESS CITY
STATE ZIP
L BJ-GC-2B (Rev. 3/0ti)
Page lof2
IIUII n II~IIIIIIIIW .J
r
GC-2B APPLICATION FOR GAMES OF
NYS RACING & WAGERING BOARD CHANCE LICENSE
I Broadway Center, Suite 600
Schenectady, NY 12305-2553
Telephone (518) 395-5400 Fax (518) 347-1469
www.racing.state.ny.us
--,
GC-[illJ- 0L]J -1~IOI:lI-~
NYS Identification Number
loIDI/~/loI11
Date
SCHEDULE 5 DATES, HOURS AND RENT OF ALL LICENSE PERIODS TO BE HELD
(NOT APPLICABLE FOR BELL JAR GAMES)
DATE HOURS
~ 1.0.3,1,0, 7.! ,D. 7 ,:,0, D,am/€)- , J,/ ,:,s,q ,am/<ED!$ ,
'----'--' I ~ I, , ,!, . ,:, , ,am/pm -. , .:, , ,am/pm!$ ,
'----'--' I . , I , ,! , , . . .am / pm - , . . , ,am / pm ! $ ,
'----'--' I, . , I . ,! , , . , ,am / pm - , , . . ,am / pm ! $ .
'----'--' / '----'--' / . ,! , ,'. ,am /pm - ,'. .am /pm ! $ .
'----'--' I '---'---' / . .! . ,'. ,am /pm - .'. .am /pm ! $ .
'----'--' / . , / . ,! . . . . ,am / pm - . . . . ,am / pm ! $ .
. . I . . / . ,! . , . . ,am / pm - , . . ,am / pm ! $ .
. . . I. . , I . ,! . " .am / pm - " . ,am / pm ! $ .
'--"'-' / ~ / . ,! . . . . .am / pm - , , . . .am / pm ! $ .
'--"'-' / ~ / , .! . . . , ,am / pm - . . . . ,am / pm ! $ ,
./ ~ /. ,1. ,'. ,am/pm - . ,.. .am/pm!$.
RAFFLES
DATE
RENT
.0,..0,0,
,- .
,- .
. . .
,II' .
.. .
,II',
.. .
,II' .
,II' I
.. .
,/ ,
,/ .
,/ .
,/ .
,/ ,
SCHEDULE 6 EXPENSES
List items of expense to be incurred, and the names and addresses of persons to be paid.
ITEM OF EXPENSE VENDOR NAME STREET ADDRESS CITY
./ .
,I .
./ .
./ .
,/ ,
,II' .
am /pm -
am/pm -
am / pm -
am / pm -
am / pm -
."'.
PRIZES (Cash or Fair Market
Value of Merchandise)
,am / pm ! $ . . . . . " .
,am / pm ! $ . . . . . , . , .
,am/pm !$. . ,
,am / pm ! $ . ' . ,
,am/pm !$. ,'.
TIME
I
. I .
I
.1 .
I
. I .
I
. I .
I
..,
,II' .
oil',
,II',
.. .
,II' .
. I .
,II',
,II',
STATE
ZIP
L BJ-GC-2B (Rev. 3/06)
Page lof2
11111111111111111111111111111 ~
TOWN OF WAPPINGER
TOWN CLERK
CHRIS MASTERSON
TOWN CLERK'S OFFICE
20 MIDDlEBUSH ROAD
WAPPINGERS FAllS, NY 12590
(845) 297-5771
FAX: (845) 298-1478
July 23rd, 2007
Adrian Anderson, Sheriff
150 North Hamilton Street
Poughkeepsie, NY 12601
Dear Sheriff Anderson:
Enclosed, please find a copy of the members of the Wappinger Elks #2609,
Route 376, Town of Wappinger, who will be conducting Games of Chance
on August 5th, 2007.
SUPERVISOR
JOSEPH RUGGIERO
TOWN COUNCIL
WilLIAM H. BEALE
VINCENT BETTINA
MAUREEN McCARTHY
JOSEPH P. PAOlONI
I would appreciate your review of the "Members in Charge" listed on the application.
Please complete the "Findings and Determination" form attached and return the form
to our office.
Thank you for your attention to this request and your prompt reply.
Yours truly,
Ene.