Wappingers Elks Lodge #2609
r
GC-4
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
I
FINDINGS AND
DETERMINA TION
FOR GAMES OF CHANCE
LICENSE
GC - rn - [ililiJ - [UiliJ - ITIQLLJ
N.Y.S. Identification Number
Town of Wappinger
Name of MunicIpality
. 1195 Route 176, W~pp;ngpr~ F~ll~, NPM York 12590
Address
After investigation, and a hearing if required under Sec. 192 of the General Municipal Law, the following findings and determinations
have been made:
1. All the members-in-charge designated in the appli ~es 0 No
character and have never been convicted of a ci"
Signature of Person Conducting Investigation
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 Games
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 to be paid to an authorized games of chance lessor is reasonable.
10. Other findings: (Specify)
~es DNo
0Yes DNo
~es DNo
~es DNo
~s DNo
~s DNo
~es DNo
DYes DNo
DYes DNo
TO BE COMPLETED BY MUNICIPAL CLERK: /'
As a result of the findings and determinations stated above, license is GRANTED 0i license is DENIED D
Signature of
Filing date of Application April 24. 2007 Authorized Officer
Date 5 f.:if (; l Title -rOV.Ji) L ~
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 FIRST AUTHORIZED LICENSE PERIOD.
L BJ-GC4 (Rev. 4/03) 11111111111111111111111111111 .J
TOWN OF WAPPINGER
TOWN CLERK
CHRIS MASTERSON
SUPERVISOR
JOSEPH RUGGIERO
TOWN CLERK'S OFFICE
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS, NY 12590
(845) 297-5771
FAX: (845) 298-1478
TOWN COUNCIL
WILLIAM H. BEALE
VINCENT BETTINA
MAUREEN McCARTHY
JOSEPH P. PAOLONI
May 3, 2007
Wappingers Elks #2609
1195 Route 376
Wappingers Falls, New York 12590
Dear Ms. Kultsar:
Please find the attached "License to Conduct Games of Chance" for
your Las Vegas Night to be held on May 4, 2007. I have also attached a
receipt for your payment.
Please do not hesitate to contact my office with any further questions
or concerns.
Sincerely,
I
GC-5
-,
LICENSE TO CONDUCT
GAMES OF CHANCE
PLEASE CHECK
GAMES OF CHANCE [X!
BELL JAR 0
RAFFLE 0
GC - [iliJ - ~- [ilili] - ~
N.Y.S.ldentification 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: 1195 Route 376 City: Wappingers Falls
Entire net proceeds to be devoted to the following specific lawful purpose(s):
1/3 Charitable 2/3 Operations
Names of Members in Charge
Zip Code: 12590
Paul Bader
Richard D. Dobbins
Simon Kaufman
Lew Hakim
LICENSE PERIOD
DATE
DAY OF WEEK
HOURS
TYFE(S) OF GAMES
MAY 4, ~007
Fri day
7:00PM-1:00AM
Black Jack. Joker Poker. Big Six
RAFFLE DRAWING
DATE
DRAWING TIME
DRAWING 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
Town of Wappinfer
(Name 0 Municipality)
May 3, 2007
(Date)
Town C]erk
(Title of Authorized Officer)
L BJ-GC-5 (Rev. 3/06)
ignature 0 ~uthorized Officer)
11111111111111111111111111111 ~
r
GC-4
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
-,
FINDINGS AND
DETERMINA TION
FOR GAMES OF CHANCE
LICENSE
GC-rn-~-GJiliJ-~
N.Y.S. Identification Number
Town of Wappingp.r
Name of Municipality
t..
unicipal Law, the following findings and determinations
Signature of Person Conducting Investigation
Title
DYes DNa
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 Games
of Chance Licensing Law and the Rules and Regulations of the N.Y.S. Racing and Wagering Board.
8. There is satisfactory proofthat 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 to be paid to an authorized games of chance lessor is reasonable.
10. Other findings: (Specify)
DYes DNo
DYes DNo
DYes DNa
DYes DNo
DYes DNo
DYes DNo
DYes DNo
DYes DNa
DYes DNo
TO BE COMPLETED BY MUNICIPAL CLERK:
As a result of the fmdings and determinations stated above, license is GRANTED D; license is DENIED D
Signature of
Filing date of Application April 24. 2007 Authorized Officer
Date
Title
(Municipal Licensing Authority)
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 FIRST AUTHORIZED LICENSE PERIOD.
L BJ-GC~ ~ev. 4/03) 11111111111111111111111111111 ..J
......
"
"
· ~r"
GC-2
"
-,
:-IYS RACING & WAGERING BOARD
J 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 CHANCE 0
BELL JAR 0
RAFFLE 0
FOR OFFICE
USE ONLY
$1 J? 5:V 0
Fees Received
~ / kaNJ / lQJ2J
Date
INSTRUCTIONS: PLEASE FILE THREE SIGNED COPIES WITH MUNICIPALITY
GC-!JTI]-~-I(qlolJ.l- ~
N.Y.S. Identification Number
IT IS A MISDEMEANOR TO MAKE ANY FALSE STATEMENTS IN THIS APPLICATION
<:10wfV (9fZ (;Jf\-rP\1v~~Q \)UTC.~S.s
Name of Municipality County
2.
3. Has applicant ever been derued a games of chance license? 0 Yes
4. Check type of organization and. if applicable. give the State and date of incorporation.
Corporation 0
I'5t. State incorporated \ ~ ." ......1 r\D~1
Incorporated Association ,,, ~ ~
Date @I] / [(fl] / ~
Date OJ / OJ / OJ
Unincorporated Association 0
State incorporated
Individual
o
5. Did your corporate status change since your identification Ilu~r was assigned? 0 Yes ~o
6. Are you doing busine.~s under a trade name? 0 Yes ~o 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. \ \ q S-R\' ~I \"
8. Name and address of authorized games of ~ I A
chance lessor renting to applicant.
Lv itP P .~ A-L-L), \..t.i ·
1
12. Are the premises or any part thereof
where games of chance are to be played
licensed by the State Liquor Authority?
13. Has such license ever been
revoked or suspended? 0 Yes
tik:'es 0 No
If "yes", state the type of licensi,~ and number.
CL-ODO/4-d-Lt~
~
If "yes", why? (Explain on a separate sheet. if necessary, and attach.)
L BJ-GC-2 (Kev.4/113)
Page 1 of2
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PARI' C. l'UIU'OSES OF C;i\(\U':S
1'1. Slal~ till' S[~et~[J\2Ja<<~I~~ ~~lll..1 pl()CCCdS ,ll~ t~t~lle~\lri~~~T\o \J ~
I ,WC'al Illl dlthllll'
Illut :\U.. :tJe all~lI.:lieLl Sl'ileLlLlII~' an~ a 11Iillerilll p<lll Iiereur <111<1 ill" ill<.'oq.HJnlteLlliclcill as it' set \Jill ill t'ull illlhe upplicaliull. All the Ul1swc'rs
,'UlliJIIICLl III ihis ilppli-:'Iliun arc' a material pWI hereu!.
I hU111I<.' <.'11111<.' 11<.'1 pl\xC:cds vi all gume; of dli\Jle~ shull b~ J~\'(l\~J ~Xclllsivel)' 10 one Ill' more Ill' the; "lawful purpos~s" us llet1ned in the GIlIlles vi'
Challe-I: LJ,'l:lIsillg L1W :;.Ill..llhe ({Liles and Regulations of the HI)ard,
.'. Thattur cadlll"ells,: peri<..J lor which a lice,llse is sought, \lilt: or 111m,. ut'the al:livc lIleulbl;:rs IIIlJt.ll whose Sllpelvisionlhc:: galllcs are to be held,
\lfJcnueJ ;lnd cundu\:teJ. whu is tUIll.i1iur with the GUiIl\:S of Chance Licl.:lIslng Law, the Rules and Regulutions of (he N, Y.S, Racing & Wugenllg
Lic1urd 1lnd Ivc'.llicellsilll) vn.lin,me'c, or lmvs, will be pre'sell! al <III limes, in charge und prilllilrily responsible for the wnduct of games,
4. Jllul llle lllldersigll\:d will bc'. rc~spull,Slbk fell tbe Iwlding. opl:rUlioll allll CllllJlll..Ol of ulI glllll\:S ur clHUlce ill uC<":lJnlllllCe willi llie tcnllS of tht.lli<.'ens<:..
llle fJlU\ISiullS \It'the CiVile'S ut'Dldn-:," Lkcn:;ing 1"lw,tI1<: RlIk~ lIIld R\:grdati\llls of the N,Y.S.lhll'lllg ,\:( Wagering Board alld willI tlie prc\YlslUI\S
,)( I,.K',I. 11L'c.nslllg onJlnill\c'c.1 ur hlws.
\ ltlUI \lle 1I11i.krsigned hilS reaJ and is fUlIllli"r with Ihe pfllvisiLlllS 01' Ihe C;UlilJ;lS ur CIHUICI.: Licel1sillg L"w ilS ,unellllcd, the Rules ilnd Regul,lliol1s
l)11:1~ :~ y .s. I~ilcij}g & \\ "gcnng Buurd, mllJ ttle IDCld li<..:t;nsJllg onltnal1>':cs or laws,
(), Thlllll\l c'DllIllli,si,Jll, sahl,.y, ClllllPI;:llsution, rewurd or recOlllpl;\llSe will be paid to allY person for tlOlding ur assisting III tlie operuung or
""IHjuc'ling elf me gunICs, exc<:pl 10 bUDkkeepe.rs or acCollntants ror jJfIlk,siollUI service, in an aJllolllltnull.:,\cecdillg t!l,1t tixed by the 130l\rd,
11GJ/IL5liJ / ~I1J~~~ii/ii<y- ____1J~~1c.. ~ kull-~?, r
Dail;' Slgndlllre:'ol Head ul Urgallll,illlon l'nllL Name
Ol' NEW YORK
:::~~ }ss
..B:...o~~._~_~~~Jd::;oc-A..; _________. bl:ing dUIY:WUfIl tlt\poses ami says thaI (S)llC is the pl~rS()1l above llull1cll,
Ihill !s'k k.j :..:ad ill..: fUI>.:t;,\)iilg Slllleillenl and thl! allswer thl~leinllutcd, lllld that such :.lIlSWl!rS ale tnll! Hno thul (slhe has personally
iill!.\c": hiS (her I Slgll,lllll\~ :u ulis anid"Ylt.
>;1.,\11.::
CUUNTY
(Try/' ['( J\V No'\' ILL/\U 1-
s,,, " " Ie> Ik'''' "" II~,,- ht:_ "'y ,I ~. 20~ Slgl"O~~ ~~. f......~
_.__~-J. h~1J'rJs -..-.-- __ .----------
)\tllillY Pullin.: COl1llllissiollt.~r of Deeds
1Vly (\IIIUt!iss;OIl,''\jlircs _~_.._;30__, '201JL_.
L L\J.(,C.~ \/{rY, 4iOJi
Pagl;' 2 \)1)
11111111111111111111111111111 ~
'.r:"
GC-2A
-,
NYS RACING & WAGERING BOARD
I Walervliet Ave. Ext.. Suite 2
Albany. NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.l.8Cing.state.ny.us
APPLICATION FOR GAMES OF CHANCE LICENSE
f r \
Name of Organization
GC- [illJ- ~ - [muJ- ~
NYS Identification Number
SCHEDULE 1: OFFICERS AND DIRECTORS
Ust names. addresses and dales of binh of all officers.
If organization is a corporation. or an incorporated or unincorporated association, Iisl officers and directors.
TITLE N~...-AI ILz.... DAT-G Q{ B~TH STREET ADDRESS CITY
IC~~~ tIt'.~~\t..L/_1 I
1 1_1_1_1 I
I 1_1_1_1 I
I 1_1_1_1 I
I 1_1_1_1 I
1 1_1_1_1 I
I 1_1_1_1 I
I 1_1_1_1 I
I 1_1_1_1 I
I 1_1_1_1 I
I 1_/~,b-1 I
Attach additional sheet if necessary.
MEMBERS IN CHKRGE OF GAMES
(MUST LIST AT LEAST FOUR MEMBERS OF APPLlC~ ORGANIZATION)
DATE YEARS OF
NAME OF BIRTH MEMBERSHIP STREET ADDRESS CITY ZIP
?~L. ~~~~I HLI "S-I---LLI\;...{ ~~~ROj~pt~'~ ,;).SL{1)
~\c..\~ 00~Bu/1 ~ 1 :!2QI ~1-13-1 <'0 ~ W-U~J..fi:- \.) R. I~()f -~ I l ~ S1 t=>
~\\-{O\J l<~~1 --Lk.1 ~I~I <t ~unt- "'l~lP u.., ,~~fi... Jtj"-. 1 \')..~; ~
'-Iilu t.a.'~\"" I ~I .n.1 ~I 3 I ~V ~~ ~ ~ ~'-'At>" .\FA-L-l~ ()..~--q1)
. 1_1_1_1 I I I
1_1_1_1 I I I
1_1_1_1 1 I I
1_1_1_1 I I I
1_1_1_1 I I I
I 01 Ofl 1 ~ 1 @ill
Date
ZIP
SCHEDULE 2:
SCHEDULE 3: AUXILIARY/AFFILIA TE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF 2 AUXILIARIES/AFFILIATES. EACH AUXILIARY/AFFlLlATE LISTED MUST HA VB ITS OWN ID NUMBER.)
L~~:O~:U)\Y/AFFlUA~ O:::F CHANCE ID NUMBER 1IIIIIIgIII ~
. r.SCHEDULE 4: ASSISTANTS TO MEMBERS IN CHARGE OF GAMES
List u11 members of npplicunt organization and membclll of nuthori:r.ed affiliates and auxiliary who will assist with games. Each person liSled must be a
member of npplicllllt or~nniZlltion or affiliate for allenst I year.
YEARS OF
MEMBER NAME . DATE OF BIRTH MEMBERSHIP STREET ADDRESS
I 1 1 '_I
(C,~ 1=1=1= I _ 1
~ ~I_I_I_I_I
~l~) 1_1_/_1_1
1_1_/_1_1
1_1_/_1_1
I / 1 I_I
1=1=/= I _ I
I. 1 1 I_I
1=1=/= I _ I
1_1_/_1_1
I / 1 I I
'=1=1= I = 1
, 1 1 I I
1=1=/= 1 = I
I 1 1 I I
1-1-/-1-1
1--/-- 1- I = 1
1-1-/-' ,.;\.
'-1-1-1-1,
,- 1-1- I - ! )
1=1=1= I = I
I 1 1 I I
'-1-1-' - I
1=1=/= I = I
1_1_/_1_1
1_1_/_1_1
1_1_1_1_1
'_1_1_1_1
I 1 1 I_I
1-1-/-1 I
'-1-1- I = I
1=1=/= I _ I
1_1_/_'_1
L 8J.GC.2A (Kev. 4/03)
Attach additional sheet if necessary.
Page 2 of 2
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CITY
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ZIP
Schedule 1: Officers and Directors
WAPPINGER LODGE #2609 OFFICERS for 2005-2006
Title Name Address Town 0 Zip DOB
Exalted Ruler Steve Drobnak 53 Moccasin View Rd. Fishkill 12524 02/02/1957
Leading Kgn Pamela Kultsar 58 Hillis Terrace Poughkeepsie 12603 02/01/1950
LoyalKgn Derrick Mills Pawling Lake Box 17 Pawling 12564 10/10/1940
Lect. Kgn Sandra Seekamp 67 Pawling Lake Pawling 12564 12/10/1945
Esquire Mark H. Fox 28 Tiger Road Hopewell Jct. 12533 09/1511957
Chaplain Diana M. Cole P.O. Box 549 Hughsonville 12537 0412511948
Inner Guard Rosemarie Perretta 35 Cathy Road Poughkeepsie 12603 09/07/1943
Secretary Robert M. Acquanita 10 Vorndran Dr. Wappinger Falls 12590 0512511942
Treasurer Richard O. Desruisseau 183 Red Cardinal Court Poughkeepsie 12603 11/0511936
Tiler Jacqueline Alfano 93 Brothers Rd. Wappinger Falls 12590 08/27/1938
Trustee Patrick J. Moriarty 26 Robert Lane Wappinger Falls 12590 04116/1941
. T 1111 17._1 W. IhJ_. DOD .....<1.""........ I\u. _~I C111~Y..n; I "'~v v." ",v, I JViJ ~
Trustee Harris Jones 102 Brothers Road Stormville 12582 04124/1944
Trustee Gerhard P. Stoetzel 662 Noxon Road Poughkeepsie 12603 0510211942
~ ... .. . ... .. . . .. --- - .. 1 ... ..J .., , .. on TT ..y.--........ .
No Officer receives compensation of any kind.
. .
,.
Schedule 4.' Assistants to Members in Charge of Games
First M I
Frank
Philip A.
Ralph J.
Henry J.
Harold A.
Francis J.
Roger
Richard O.
Richard D.
Stephen F.
Robert
Mark H.
Harris C.
Robert J.
Joseph
William K.
Eugene P.
Rosemarie
Gregory F.
Kenneth J.
Robert N.
Last Name
Abato
Abbate
Anzivina
Boldrin
Crawford Sr.
DeGano
DeJordy
Desruisseau
Dobbins V
Drobnak
Fischetti
Fox
Jones
JuNano .
Jurina
Minkowski PSVP
Pampa lone
Perretta
Sarno
Tucker
Wallner
DaB Address
04/24/1940 39 Kensington Drive
05/16/1937 6 Hackensack Hghts Rd
12/21/1935 12 Thorns Lane
01/11/1936 28 Gold Road
02/23/1936 318 Sunset Hill East
07/18/1946 27 Brandy Lane
09/19/1944 83 Kent Road
11/05/1936 183 Red Cardinal Court
05/30/1949 6 Schuele Drive
02/02/1957 53 Moccasin View Rd.
06/07/1926 91 Ardmore Drive
09/15/1957 28 Tiger Road
04/24/1944 217 Brothers Road
10/05/1953 2776 West Main Street
02/28/1963 173 Hillside Lake Rd.
03/20/1942 427 McGrath Blvd.
09/03/1936 53 Helen Drive
09/07/1943 35 Cathy Road
07/01/1936 13 Dana Place
03/19/2029 34 Pawling Lake
01/17/1933 7 Kinry Road
Town
Hopewell Jct
Wappingers Falls
Highland
Wappinger Falls
Fishkill
Wappingers Falls
Wappingers Falls
Poughkeepsie
Wappingers Falls
Fishkill
Wappingers Falls
Hopewell Jct.
Stormville
Wappingers Falls
Wappinger Falls
Fishkill
Wappingers Falls
Poughkeepsie
Wappingers Falls
Pawling
Poughkeepsie
Yrs an Elk
8
15
18
12
15
15
15
18
19
6
25
11
15
10
7
25
17
5
25
6
16
I
GC-2B
-,
NYS RACING & WAlIERINCi BO;\IW
I Wult:rvlit:l AVI:. Ext., Suite 2
Alh<lll)', NY t 220(}..166H
Telephone (5111) 453.114()() Fux (Sill) 453 K4l)2
www.racillg.slalt:.ll)..US
APPLICATION F'OR GAMES OF
CHANCE LICENSE
.1
,. '" '. .' '41
,~..:~ ...~
~plllV~-L
Name of OrganIzatIon
GC- rn -- ~ -lliiliJ-lvl~lo h 1-;\
NYS ldentification Number
~/[ili]/~
Date
SCHEDULE 5 DATES, HOURS AND RENT OF ALL LICENSE PERIODS TO BE HELD
(1\'01' APPLICABLE FOR BELL JAR GAMES)
HOURS RENT
-R '.9 ()J;I- '0' ~ - -, lJ- vtr0/ pm 1$
,----'---...J' ~.-&.-..--* ~-..-... L......:.~~ '
,----,--,: .J!.~O~am /639 - ~..__~_,:. l '.~ 1J(!fiJ)/ pill 1$ .
, . ,---,----,am / pm . , : ,----",--,am I pm i $ , '
,: _-----.... am / pm - ,--",__-,'. ,am I pm 1 $ ...~_. ,
'---'-_~ . ,am I pm .. .aml pm i $
,_....~__~. ~__~__-'am / pm - , . ,am / pm I $ , ' .
~...~ . ,am I pm - , , am / pm i $ ..._..........-'-_
'-~-' . ,am / pm - ., am I pm l $
,_.~..___, . ~._._--,am / pill - , : ..._-----' am / pm : $ ,
. }UIl I pm - . : ~-' am I pm i $ ~~
: am fpIll-. . : am I pm ! $
'--~ ~----' ." "'-~ l.-----'--' ,"
.. ~ -,: ~~. ___,am f pm ~. ,_.~.:._ ~ .am I pm ! $ ~ .
,".
DATE
,0 71 ;- ~ J . t) "]'
. ____ _ ~:...t--. _ ..
,0, b~ / ...Qj, / ill
/ I
.._...._....._.~_-' ._~_._~ ___..........._..J
~-,/ ,/,
"'-4-.~ /. , , I ...........-'---'
/ I i
'-.., ~_........___"...l .____,........._.,...J ~~_~_. ....l..__.___.'
/ I
t.....--_t..----.. '--~-----.l .....~.~....__
/ I
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/ !
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/ / i
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,at
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,",---'---I -.....-............ ~--'
...J. l
RAFFLES
PRIZES (Cash or Fa.ir Markel
Value of Merchandise)
:$"--,- ,'~ .
i$.
!$
!$.
:$
.~---,"",_--I . ~-J
DATE
TIME
~._~.~ . ,,,---,--_~ um / pm
.._~_~. .~..~am Ipm
am I pm
t--~. ~---'
, am f pm
I \..~_.-l
. am f pm
L..__~ '."_~""r.----'
,.,
/ / I am / pm -
...._~____.. ---...___ ~-' '"-,....--0..._. _ -,. .__ -~~
/ / 'am I pm -
.-~........ / ~~--~ / ~.~----' 1 .-----,...--~: "_---L----' am / pm .
_~ ______. ~~ ' L__......._--'..
'---'--~ / '---'--' I ....----'--'! ~._.~_.: '-_"---' am I pIll
._~~ / ~-' I . . . .__..___--" ~ ' am f pm
,a,
SCHEDULE 6 EXPENSES
Ust items of expense to be incurred, and the names and addresses of persons La be paid.
lTEM OF EXPENSE' VENDOR NAME STREET ADDRESS CITY STATE ZIP
9.~\"\J'6-- t~~valt.1trl\J(t ~flt,l!~f ~.Ja--,1J.:L12537
LUlvbR L\Lt'!tJ~r~'~ Bv(,.~ Lt~b~1k. ~f.~~}-SqO
L IlJ.GC.2B (Rev. 4/0.1.\
Page [ or '2
II1I1II111 ~ 11111111111111111 .J
.
, . f--: SCHEDULE 7 TYPES OF GAMES I
List all of the single types of games to be conducted at all license periods enumerated in Schedule 5.
Note ror Ve285 NI2bts and Bazaars only; The total amount of prizes during anyone license period shall not
aggregate more than $400 for each single type of game of chance when five types of games of chance are to be
conducted during anyone license period. The total amount of prizes during anyone license period shall not
aggregate more than $500 for each single type of games of chance when less than five single types of games of
chance are to be conducted during anyone license period.
LIST NAME OF EACH TYPE OF
GAME OF CHANCE
(Limit: 5 Games)
fj 1 ~ c Ie. :::rite k...
:To t- f i. !b tit Il..
13/& Sl'~ wJJ(dL
LIST THE MAXIMUM AMOUNT OF PRIZES
TO BE AWARDED FOR EACH TYPE OF
GAME OF CHANCE (GAME BAN~)
at $ So 0 . 0 ()
at $ .1-00. () 0
at $ .5"00. cO
at $
at $
For Merchandise Wheels, Bell Jars and Raffles, please complete the appropriate spaces below.
MERCHANDISE WHEELS:
INDICATE NUMBER OF
MERCHANDISE WHEELS
(NO LIMIT)
THE TOTAL AMOUNT OF PRIZES FOR
EACH MERCHANDISE WHEEL SHALL
NOT EXCEED $10,000 AND NO SINGLE
PRIZE SHALL EXCEED $250
BELL JAR:
INDICATE IF THIS APPLlCA nON
IS FOR A BELL JAR
LICENSE
YESO NO ~
THE TOTAL AMOUNT OF PAYOUTS
FOR EACH BELL JAR DEAL SHALL NOT
EXCEED $3,000 AND NO SINGLE PRIZE
SHALL EXCEED $500
RAFFLES :
TNDICA TE IF THIS APPLICATION
IS FOR A RAFFLE
LICENSE
YES 0 NO t!-
IF YES, LIST RAFFLE DATES, TlME(S)
OF DRA WING(S) AND PRIZES IN
SCHEDULE 5
THE TOTAL AMOUNT OF PRIZES FOR
ALL THE RAFFLES CONDUCTED DUR-
ING THIS 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
L BJ-GC-:zB (Rev. 4J03)
Page 2 of2
IIIIIIIIIIIIIIIIIIUIIII .J
"1
TOWN OF WAPPINGER
TOWN CLERK
CHRIS MASTERSON
SUPERVISOR
JOSEPH RUGGIERO
TOWN CLERK'S gFFICE
20 MIDDLEBUSlH=IOAD
WAPPINGERS-OOS, NY 12590
(845) 297-5771
FAX: (845) 298-1478
TOWN COUNCIL
WILLIAM H. BEALE
VINCENT BETTINA
MAUREEN McCARTHY
JOSEPH P. PAOLONI
April 24, 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 May 4th, 2007.
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,
~c!~
J c. M terson
Town Clerk
Ene.
r-
GC-2
NYS RACING & W AGER1NG 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 CHANCE 0
BELL JAR 0
RAFFLE 0
FOR OFFICE
USE ONLY
Municipal License Number
$\ d15, ~() I lQR] / 0iJ / [QI1]
Fees Received Date
.. --.
INSTRUCTIONS: PLEASE FILE THREE SIGNED COPIES WITH MUNICIPALITY
GC - [J]2] - QITH]- Il.,;f 0 [;Lj - ~
NY.S. Identification Number
IT IS A MISDEMEANOR TO MAKE ANY FALSE STATEMENTS IN THIS APPLICATION
~O~vt-:tV (q [? tJJ n- rP \ tv G:- ~~ \)l1TC~ c;.:;
Name of Municipality- County
2.
3. Has applicant ever been derued a games of chance license? 0 Yes
4. Check type of organization and. if applicable. give the State and date of incorporation.
Corporation 0
rx.. State incorporated \ ~ . I) ,\ (\DV
Incorporated Association ., ~ ~
Date [ill] / caJJ / [ill]
DateITJ/ITJ/ITJ
Unincorporated Association 0
State incorporated
Individual
o
5. Did your corporate status change since your identification nu~er was assigned? 0 Yes ~o
6. Are you doing business under a trade name? 0 Yes ~o If "yes". what is the trade name?
PART B. LOCATION OF GAMES
7. Address where games, bell jar, or rame drawing(s) are to be conducted. \ \ q S-m- ~/1,.,
8. Name and address of authorized games of ~ I A
chance lessor renting to applicant.
9. Does the appUcant own the premises'? ~s 0 No If "yes", how long?
10. Capacity for public assembly of premises presently owned or occupied. J g ~
11. Have premises been regularly used? Lf,(cs 0 No If "yes", how long? l 9._:t rzC\--Jl.. !;;?
Are games of chance being played now on these prem~ses or has it ever been?'~Yes 0 No If "yes", give full details.
NOV ,ct> "2) .:J-O 0 fa
.
lv\\P P .~A-lL~ \v:i ·
1
12. Are the premises or any part thereof
where games of chance are to be played
licensed by the Stale Liquor Authority?
13. Has such license ever been ~fO
revoked or suspended? 0 Yes l'
ak:-es 0 No
If "yes", slale the type oflicensl~ and number.
C. L - 0 0 0,4 - :}-Lt ~
If "yes", why? (Explain on a separate sheet, if necessary. and attach.)
L BJ.GC.2 (Rev. 4/03)
Page 10f2
11111111111111111I11111111111 ..J
~.
PART C. l'l'IU'OSES OF C;.\i\'lE,'l
"''''': ''': '1:''(~P'ZlM0q~I~~ '~~1-"'" I"'''''''' me '~/~"e~"(,'~R~T\D \.i S
I s....\'l~.al \..Ul ,lClirl\\)
111"1 ..,u.. :!I~ 'lllClclleli ,",'11e<.!llks 'Ire aIWlItC'.rial!Hlrl !I~.re"f <lilll ,ue: illcorflunlled lu;tdll uS if s~.llJUI III full illlllC appli~i1liLlII. i".lIille umwc:.rs
"Hli.lIICd III elllS upplicclliUl1 arc: :lllhlleridl pllJIIlt:t\~UI.
lli,j\ llle CJllll c: Ilel pi \)IXcJ, 01 all gUllle" uf dHUK~e ,hull b~ devoted ~xdusi v~ly to (I1\e LlI' Illor~ lll' tllt; "hlwful purposes" as detlned ll\ tl\e GUIllt;:, u1
CI\JII'.~ LjL'~ming Law >iJlLl llie kllk.S m\Lt Regulalions of lh~ I)llurd,
1'I1"llur CJdllil'ells~ pcriud for Whlcll U lke,ilsc is sougltt. (lilt: Ill' IllUI"'. ufiltt: at:live 1I1eJllb<;;r~ limIer wltose sllpervi~iollllte gULlies are to bc hc:lLI,
up~raled ,(liJ cUllJu~led, wilu is fUlIuli,lr with the GUIll"S of Chanc!: Licl,:n~lng Law, Ih~ Rules <iIlU RtlgLilutiollS ot the N. Y.S. Racing & WagerIlIg
Li,J"Ld "lid 1\)c',llicCllSilll;; uldlllallL'cs lJi' laws, will he. prc'Sl'.lll al illllilllCS, ill cliarge JIllI plilllWily rtl~i'l,)lIsill1c for U1t1 cOndll(;1 of games.
;j 1\1<11 IIIC 1I1ldet,lgned Will bl' rL'spuII~lhk fIll llle llllldillg, upelUlloll HIIlI CUlldUL:1 Llf ,ill glllnes ut' <:IllUlCe in "CCIJldcllKe willi Ihe Le[[n~ of the llcell;e..
tile illU'l,iullS \llihe l.;'l,lllCS ul'CftlltlcC:: Liccnslllt( l,ilW, 111<': Rule:; unLi J{egLtlaliLlll~ oflhe N.YS,I{lIcillg 8.: Wagerlllg Bourd and willi the pI <.1VISlilll>
i)( l~)~'\il \il.:t',ll~\llg on.iil\"dIlL'L::S ur Ltws.
, T!1<11 Lilt: IIlldc'rslglle..llllls Lead al1LI is rUllIili"r Wilh Ille prllVi~il\ilS Urlftl; C;,lI11t:S Ill' Clh1111;1,: LI~t:II~illg Law liS lUIlcmkd, the Rules "lid Regul.lliuus
,,'I ill;"\ .S. !{dClilg.\.: \\ .lg,alng UL1l11d, dlld tlte locullicCllsJllg (lldlll:lnL'''S or law~.
6. ThillliU c'Ulllllll"iull, "liMY, CLlIlIP\;llSLlliOll, rew\Il'd or rt;lcoll1pens<l willtle paid t(J uny ptlrSLlll for holding 01 ussisling III the openlting Ill'
';.lildudil1g c',j' (II~ 8l!llleS. CH'<:pl to bLH)kkL>.L~pl'r~ ()l' ac:c.olinlants I'ur plllkssillllUI senices in an wlIUUlllllull,:.\ceedillg tliat tixed by the Board.
I--.~T~] / [J./J / l{~.FL1
!)alt
,
.___...__'/__:,~i...2_~~-:15l~(~~?j<~y~'._",_._- Ml'Jfc..{\. >. kk /1-.5?
Sign,lIl1!'l~ or Head urUq,>;alllOllillll Prinl NUllle
.\1.\11::
or
NEW YORK
}SS
C'I mIUWN.'\'ILL.^, iI UI' ,1Lk'f'f'-''?jeyJ,QQ,c
"I)' , . J .. J . \ ).
,_.l=c~)}::J<1i,::~__:::;?. Ki:...-~:y,:,j0 hc::ing Liuly sworn (kposcs anJ says thill (s)lIc is 11m pL~rsoll ulloVL) mUlled,
111:<1 ':i'Ii-' 11;;, ll'Ild Ilt;;10f~'~:;!Iog "1~-;;[-;;i\Jlfi~--;lS\vei: llil'lelll IIUU;d, Wid tilal sud\ Clnswers all,: llue ilnd thaI (s)ile Ilus personall)
:11 il.\C'.\: ill.', i,he!' I Slgl:aILlr~' :u l!\is aJl.id(lVlt,
l'UUNTY
( ll'
\J ~.f:rL\:trz-~?
:)\"'11111.1 Del.'le III" 11I,,'':.- J~_ \by (11 f"l.
5' i n11 .~-
__,____:-_~LLi+- "...J \ ~ill') I fv ~
)\lll:n y Public
:'-.ly (\)\I\lI:I~S:LiII cxpil1::; .._-4~4-..}L~___, '20 LQ-_
U
20~
:l
SigllL;d _~,",.j;-~
..,L ../(~k;z/J--~>
. '" .
. '-: f--
COl\llIlissiom~[' lit' Deeds
L l1J-(,(',~ (({n. ~i()J,
1.lHc~,t: '2 1.)1 .-)
1111111I111111111111111111111 --1
,
f P \
Name of Organization
GC- [ill] -lliill) - (illQl- ~
NYS Identification Number
SCHEDULE 1: OFFICERS AND DIRECTORS
List names. addresses and dates of blnh of all officers.
If organiz.alion is a corporation. or an incorporated or unincorporated association. list officers and directors.
Tl11.E NAME~ DATE OfBIRTIl STREET ADDRESS
\C0lt~ If t'f.~~'t-L/_I I
1 1_1_1_1 I
\ 1_1_1_1 I
I 1_1_1_\ 1
I 1_1_1_1 I
1 1_1_1_1 1
1 1_1_1_1 1
I 1_1_1_1 I
1 1_1_1_1 I
1 1_1_1_1 I
\ I_I ~t._1 I
':-4'
Attach additional sheet if necessary.
APPLICATION FOR GAMES OF CHANCE LICENSE
-'
:;C-2A
-lYS RACING & WAGERING BOARD
I Water/liet Ave. Ext., Suite 2
/\Ibany. NY 12206-1668
relephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
~/@]/@l]
Date
CITY
ZIP
\
\
\
\
\
\
\
\
\
\
\
SCHEDULE 2: MEMBERS IN C RGE OF GAMES
(MUST LIST AT LEAST FOUR MEMBBRS OF APPLlCANT ORGANIZATION)
DATE YEARS OF
NAME OF BIRTIl MEMBERSHIP sTREET ADDRESS CITY ZIP
<0lv l- Pz9!;l.t(J,.-'l1 .l5!_.J Co Sl.-U-I \ ~ M11)R~ RQ j ~~b'lwh \~S'L( 1)
~\U~ o.,{),f'>\II!>~/.:2Q1 ~1-13J f., ~~~v<- Q R. I~~f .~ 1 l~ ~ '"
<;\\.{O" l~ og/..JlL1 ~1=.1:-1 ~ ~\fl1I-V\l~'" u.., ~~:...~(i... ''1~, \ \1-~? ~
Wilu ~ V\ 131:EL I.!S-I ." 1 )..\' 4l~ ~ l.<f ~1u(W .1I"k-L 71 1)-:) q-o
1_1_1_1 I 1 I
1_1_1_1 1 1 I
1_1_1_1 I 1 1
1_1_1_1 \ \ 1
1_1_1_1 \ \ \
SCHEDULE 3: AUXILIARY/AFFILIA TE ORGANIZA TlONS ASSISTING AT GAMES
(MAXIMUM OF 2 AUXu.lARIESIAFFlLlATES. EACH AUXILlARY/AFfILlATE LISTED MUST HAVE ITS OWN JD NUMBER.)
NAME OF AU~Y/AFFJL\ATE GAMES OF CHANCE ID NUMBER
L BJ",C~' ..". '103) -. - Page 1 of 2 ~ 'MIIIM~lml.1 .J
SCHEDULE 4: ASSISTANTS TO MEMBERS IN CIlARGE OF GAMES
Li. ,n .~_ or ,,,li'"'' "...i~'i'" "" ",.m_ of ,,,OOri"" ..f"i"~ ",d ...,in", woo win ...., wiili "'~. "'" P&W' li"'" m'" '" ..
member of nppliClllll orJl;nni7.lltion or affllinte for allellSt 1 year.
YEARS OF
.!EMBER NAME . DATE OF BIRTH MEMBERSHIP STREET ADDRESS CITY
1_1_1_1_1 1
'c, ~ 1 1 1 1 I I
~~I_I_I-I-I 1-
= 1:>-\'>1) 1- 1- 1- I - I 1
\=1=1=1=1 I
1_1_1_1_1- I
1_1_1_1_1 I
1_1_1_1_1 I
1.'--1_1- \ - I I
1_1_1_1_1 1
1_1_1_1_1 I
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 _I 1
\__1__1- I - I 1
1_1_1_1_1 I
1__/_/_1_1.; I
\_j_j- \ _ \i \
1=1=1=I=i 1
1_1_/_1_1 1
1_1_/_1_1 1
I_I _I _ 1 _ I J
I_I _I _ I - \ 1
1_1_/_1_1 1
1_1_/_1 _I 1
1_1_/_1 _I 1
1_1_/- \ _I 1-
\_1_1_\ _I I
1_1_/_1 _I 1
\_1_1_\ _\ 1
1_1_/_1_1 I
~ ,
ZIP
\
\
\
\
\
\
\
\
\
\
\
\
\
\
\
I-
I
\
I-
I
\
\
\
\
\
L liJ.GC.2A (kev. 4103)
Attach additional sheet if necessary.
Page 2 of 2
IIII \ I'll" I \1\11 I\U\ , 1\\1 \1 .J
Schedule 1: Officers and Directors
WAPPINGER LODGE #2609 OFFICERS for 2005-2006
Title Name AddresS T OYlO - Zip OOB
-- - ----- -- -----
Exalted Ruler Steve Drobnak 53 Moccasin View Rd. Fishkill 12524 02/02/1957
Leading Kgn Pamela Kuttsar 58 Hillis Terrace poughkeepsie 12603 02/01/1950
Loyal Kgn Derrick Mills PawUng Lake BoX 17 Pawling 12564 1011011940
Lect. Kgn Sandra Seekamp 67 Pawling Lake Pawling 12564 12/1011945
Esquire Mark H. FoX 28 Tiger Road Hopewell Jct. 12533 0911511957
Chaplain Diana M. Cole P.O. BoX 549 Hughsonville 12537 04/2511948
lnner Guard Rosemarie Perretta 35 Cathy Road poughkeepsie 12603 0910711943
Secretary Robert M. Acquanita 10 Vorndran Dr. Wappinger Falls 12590 0512511942
Treasurer Richard O. Oesruisseau 183 Red Cardinal Court poughkeepsie 12603 1110511936
Tiler Jacqueline Alfano 93 Brothers Rd. Wappinger Fans 12590 0812711938
Trustee Patrick J. Moriarty 26 Robert Lane Wappinger Falls 12590 04/1611941
Trustee Harris Jones 102 Brothers Road Stormville 12582 04/24/1944
Trustee Gerhard P. Stoetzel 662 Noxon Road poughkeepsie 12603 05102/1942
No officer receives compensation of any kind.
Jle 4. Assistants to Members in Charge of Games
;t M\ Last Name 008 AddresS Town Yrs an Elk
Abato 04/24/~ 940 39 Kensington Drive Hopewell Jct 8
A. Abbate 05/~ 6/~ 937 6 Hac\<.ensac\<. Hghts Rd Wappingers falls ~5
,J. Anzivina ~ 2/2 ~ / ~ 935 ~ 2 ThOrns Lane Highland ~8
y J. 80ldrin 0~/11/1936 28 Gold Road Wappinger falls ~2
Id A. Crawford Sr. 02/23/1936 318 sunset Hill East fish\<.ill ~5
cis J DeGano 07/~ 8/1946 27 8randy Lane WappingerS falls ~5
:H DeJordy 09/19/1944 83 Kent Road WappingerS falls ~5
lard O. Desruisseau 11/05/1936 183 Red Cardinal Court POUgh\<.eepsie ~8
lard D. Dobbins 05/30/1949 6 Schuele Drive wappingerS falls ~9
;:>hen f. Drobna\<. 02/02/1957 53 Moccasin View Rd. fish\<.ill 6
)ert Fischetti 06/07/1926 91 Ardmore Drive wappingerS Falls 25
rk H. Fox 09/15/1957 28 Tiger Road Hopewell Jct. ~~
rris C. Jones 04/24/1944 217 Brothers Road stormville ~5
bert J. Juhano 10/05/1953 2776 West Main Street wappingerS falls 10
seph Jurina 02/28/1963 173 Hillside La\<.e Rd. wappinger falls 7
i\\iam K Min\<.ows\<.i PSVP 03/20/~ 942 427 McGrath 8lvd. fish\<.ill 25
Jgene P. Pampalone 09/03/1936 53 Helen Drive WappingerS falls H
osemarie Perretta 09/07/~943 35 Cathy Road POUgh\<.eepsie 5
,regol)' F. Sarno 07/0~/~936 ~3 Dana Place Wappingers falls 25
~enneth J. Tuc\<.er 03/19/2029 34 Pawling Lake Pawling 6
~obert N. Wallner O~ /17/~ 933 7 Kinl)' Road POUghkeepsie ~6
\
APl'LICATION l"OR GAMl'~S OF
CHANCE LICENS1<~
-26
: \{!\C\I~C; 8; W AliERINCi BOAFD
u\t:ryliel ;\vt:. E~,\., Suite '2.
"n y, ~~ y \22(){)- \ 6()!l,
cphone (')\8) 453.84l,() h\~ \5 \'() ,+5.) ):\4')2
w .racing.,t:1lf..i\Y .\.IS
~~~~~
Narnc of Organ.1IUUOn
GC Cill1.. ~ - @ili\ - @.~
N)'S \.dentlfica\lOn NUlnber
W:\/W3\/ro
Date
SCHf:DULE 5 DA'fES, }lOURS !\ND RENT OF !\LL UCENSE PERIODS TO BY, }If:LIJ
(NOT APPLICABLE FOR BELLlAR GAMES)
D.~W. HOURS RENT
, /. \$
~ . =-'" ~ ~~.-::;' ~.:..~ _""~ . pm..~' ~~
S2.':>) J2'i 1 ~Q_') _~:~~am/@9' ~......--':~!PHI "1$ .~.~---_..-'
......' i ~~~ 1 ~....._" '. ~'. ...._._.Pm ! pm ' .........-' : .........-' am ! pm I $ -==-------' ~
II! ' anI / P'~ . . am / pm \ $
-" -~ .----- ~. ~ ~~'.........-' ~-~~' ~
i 1 . anI/pm . . am / pm 1 $
--,~ -' -~ .~~_..., ~ .........-'. .........-' . ~. ~-~
.....,.. 1 ..._.' 1 .....,..: _._.~: ......_ am / pm . .......--':.........-'am / p,n I. $ ~' ..~
....__' 1 ._~! __.- '_'~ : _.......-"am / pHI . .~ : -......-" a\\1 / pm \ $ ..~_.~_.J' .. ...
._____ 1 ._~ 1 ...........: ___~: ~ am I pm . .........-': .........-'al1l ! pIn ! $ ~. ~
__.1 ._'~ 1 ........_ ...._.:_.~..~anliPfil . ...--':_~aIu!pm "$ ~._-~
_.....1 .~ 1 .~.' _,:~an,/pm " ...--':..----.am/pm'$ .....~~._...-
I / i $
: anll pm' . : arul pm \. .
--- -'- -' .....................~ ....--' ...--' -~ ~
~ I . 1 i '. am I pm .. : am I I'"' I $ .
- ....-.. ...-' --~~
Rt\VVLl~S
DArE
1 1 I . am I pm .
~_.______.. ~__----' ________~ ~ ...__...... J . .......--------'
._.,_ i ~~ I _..........! ......~: .._~ ilU' I plu .
1 ! \ . ,"u f pm .
~-----....... ----' ~......-~ .-...-..~---' . ,.-------"----'
.._"! ~! ............ \. ._...:........~ ,"u I pm
i ! \ . alU I pm
~'------.----'.. ~~. ......-"...~
------~.
SCHEDl\LE 6 EXPf:NSES
Li" ,'elll' of expe",e \0 be ,"eufled. and the Hollies and addresSes of persons 10 I:>e pard.
[rEM Of EXPENSE' VENDOR NA.MF. STREET ADDRESS cITY STA.TE Z.1P
~ \(~v~lA~~VJ..,\:6j~
w~~~~v~~f~~p.l}S
: atn / pm
I--_~-' ~__.J:
: am / rIn
~..-__.-l-_..-J ~__.J.
, am I pm
._....-~.........->---........
, am / 'pm
~. c..........-'----'
" al1\ / -pm
~--~~~ >~.--"""~~----'
PRIZES (Cash or Fa..ir MdrKel
Yalue of Merch<mdise\
,,$ ~---~..----'
i, $ __________~-....... ----....-'
!, $ ~-~. ....----..~
:,,$~""""'~
i, $ ~_------=~. .........---.-.
TIME
..--,,'--""'" .-------------- ----- ------ -- ---
--- ------......----- ..------ -------- -- ---
-.---------- .--------- --- ...---- -- ---
~\,\ \ \U\\\~\\ \~U \\ .J
Pag\. \ uf '2
L Il.l-GC-;>.B (Rev. 411):.'0)
SClIEDULE 7 TYPES OF GAMES - \
List all of the single types of games to be cooducted at all \icense periodS enumerated in Schedule 5.
, . .
Not. for V. as I'll blS and Ba""'''' on\ : The towl amount of prizes during any ooe license period shall oot
aggregate more than $400 for each single type of game nf chance wheo ~ types of games of chance are to be
conducted during any ooe \icense period. The total amount 01 prizes during anyone \icense period shall not
aggregate more than $500 lor each single type of gameS of chance when ~s than fi~ single types 01 games 01
chance are to be conducted during anyone \icense period.
LIST NAME OF EACH TYPE OF
GAME OF CHANCE
(Limit: 5 Garnes)
{jlflC/c. :::rf}~ at
.::rof.f~ PoI-IlL __ at
lJi G S/~ wlUG . at
LIST THE MAXJMUM AMOUNT OF PRIZES
TO BE AWARDED FOR EACH TYPE OF
GAME OF cHANCE <.Y!' ME BANK)
$ 500,00
$ ,s 00. 0 0
-
at
= at
$ 6"00. 00
~-
$
$
For Merchandise Wheels. BellI"'" and Raffles. please complete the apjl",priate spaces beloW.
MERCHANDISE WHEELS:
=--=-=
-'
INDICATE NUMBER OF
MERCHANDISE WHEELS
(NO LlMrf)
THE TOTAL AMOUrIT OF pRJZES FOR
EACH MERCHANDISE WHEEL sHALL
NoT EXCEED $10.000 AND NO SINGLE
pRIZE SHALL EXCEED $250
BELL JAR:
THE TOTAL AMOUNT OF PAYOUTS
FOR EACH BEL\..IAR DEAL SHALL NOT
EXCEED $3.000 AND NO SINGLE PRIZE
sHALL EXCEED $500
INDICATE IF nuS APPLlCA TION
1S FOR A BELL JAR
LICENSE
YESO NO ~
RAfFLES :
IND1CATE lFTHIS APPLICATION
IS FOR A RAfFLE
LICENSE
yr,sO NO. ~
IF YES. LlSTRAfI'l..E DATES. T\ME<.S)
OF DRA WlNG(S) AND pRIZES IN
SCHEDULE 5
THE TOT AI- AMOUrIT OF pRJZES FOR
ALL THE RAfFLES CONDUcrED DUR-
ING THIS 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
\U\\\"\,\\\\\~,, .J
Page 2 of 2
L BJ-GC-1B Ole.... 4103)