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The 4065 Club Inc '.. , . r GC-2 I 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 APPLICATION FOR: PLEASE CHECK GAMES OF CHANCED (Casino Nights, Bazaars, Carnivals) BELL JAR Ba RAFFLE 0 (only raffles wI over $30,000 net profits in calendar year) FOR OFFICE USE ONLY $1 ?'l 00 Fees Received GIlJ / OJ / rn Date INSTRUCTIONS: PLEASE FILE THREE SIGNED COPIES WITH MUNICIPALITY GC - rn - [iliGJ- [Jill- ~ N.Y.S. Identification Number IT IS A MISDEMEANOR TO MAKE ANY FALSE STATEMENTS IN THIS APPLICATION Town of Wappinger Dutchess Name of Municipality County 2. Address 339 Route 82, Wappingers Falls, NY 12590 3. Has applicant ever been denied a games of chance license? 0 Yes RJ No If "yes", why? (Attach extra sheet if necessary) 4. Check type of organization and, if applicable, give the State and date of incorporation. Co~orotioo ~ State incorporated New York Incorporated Association 0 Unincorporated Association 0 State inco~orated DateITJ/ITJ/rn DateITJ/ITJ/ITJ Individual o 5. Did your corporate status change since your identification number was assigned? 0 Yes 0 No 6. Are you doing business under a trade name? 0 Yes fiNo If "yes", what is the trade name? PARTB. LOCATION OF GAMES 339 Route 82 7. Address where games, bell jar, orraffle drawing(s) are to be conducted. Wappingers Fall s, NY 12590 8. Name and address of authorized games of chance lessor renting to applicant. 9. Does the applicant own the premises? XXYes 0 No If "yes", how long? J O. Capacity for public assembly of premises presently owned or occupied. 250 11. Have premises been regularly used'?fiYes 0 No If "yes", how long? 1970 Are games of chance being played now on these premises or has it ever been? 0 Yes 0 No If "yes", give full details. 12. Are the premises or any part thereof where games of chance are to be played licensed by the State Liquor Authority? Kl Yes 0 No If "yes", state the type of license and number. on Bremises liquor license 2 03-2 ~ltche~~ OF 510252 13. Has such license ever been If "yes", why? (Exp]ain on a separate sheet, if necessary, and attach.) revoked or suspended? 0 Yes iI No L BJ.GC.2 (Rev. 4/03) Page I 01'2 1111111 II II Iltlllllllll 11I111 -1 '. . r PART C. PURPOSES OF GAMES 14. State the specific purposes for which the entire net proceeds are to be devoted and in what manner. charity, patriotic, youth, educational I I swear (or affirm): I. 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 Rules 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 terms 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 th ames of Chance Licensing Law as amended, the Rules and Regulations of the N. Y.S. Racing & Wagering Board, and the local licensing or nances o,rlaws. aid to any person for holding or assisting in the operating or ional services in an amount not exceeding that fixed by the Board. 6. [Q[[] / DB / (ill] Date IAJ(LUi~ Print Name ~CAM?{)i l ST ATE OF NEW YORK }ss COUNTY OF Dutchess CITYfTOWNNILLAGE OF Wappinger Will iam S campo 1 i 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. Sl'gned \. j~ d/l:Jj. .A ~ ~lc \ I n Sworn to before me this J1th dayof llh\J.alY ,20~ _L V~_~~L1l,,~ ~C\V\i ~n ~ I l' Notary Public Commissioner of Deeds My Commission expires ~L\..Y '}.., -, 20 0'" .. .Aft'l AI'" ~HOUJ. II.U" ".""e, ..... .r II.., 'I.,1r II.. ...C,.7IJIO e..""." ,. ...e.... c...., c...,..,.. ..",.. ..1171 C., L BJ.GC.2 (Rev. 4/03) Page 2 of2 11111I11111 II 1111111 ~ 1111111 .J ',-r'o. , GC-2A APPLICATION FOR GAMES OF CHANCE LICENSE NYS RACING & WAGERING BOARD 1 Watervliet Ave. Ex!., Suite 2 Albany, NY 12206-1668 Telephone (518) 453-8460 Fax (518) 453-8492 www.racing.state.ny.us I Name of Organization GC-rn-0TI-E0D-~ NYS Identification Number SCHEDULE 1: OFFICERS 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 CITY ZIP President I William Scampoli l-1LhU_1 1973/162 White Pond I Stormvillel125R2 Treasurer I Floyd Scholz I-.lliL/~/1952125 Clover Hill I PoughkeeDs~e12603 Secretary I Paul Taesatano 1~/~/195~33R Cary Road I Fishkill 112524 Director I Bill Hunt I...liLI ~I .l.21:L21109 Jackson s't. I F; !=lnk; 11 /, ?S?l~ Director I Peter Cassidy 1-11!!....1 ~I l2.Q5151 Orchard Place~opewell .Tcb 1/1)11 Director "1 Jerry Albanese 1~/~/1957152 Hemlock Drive/Hopewell Jct.12533 Director. I Wally Wych 1~/~/195~193 Old Sylvan UakeHopewelll Jct12533 1 1_1_1_1 I I 1 1_1_1_1 I I 1 1_1_1_1 I I I 1_1_1_1 Attach additional sheet if necessary. OJ/[D/OJ Date SCHEDULE 2: MEMBERS IN CHARGE OF GAMES (MUST LIST AT LEAST FOUR MEMBERS OF APPLICANT ORGANIZATION) DATE YEARS OF NAME . OF BIRTH MEMBERSHIP STREET ADDRESS CI1Y ZIP Peter Cassidy I 04 109 I 19651 21 I 51 Orchard Place IHooewell .let 11 ?1)11 Floyd Scholz 1--08 I 0;;- I 1952/ 29 "25 Clover Hill Dr Ip()l1ghkppp~; p 111(;01 Wally ~vvch 1 09 I 03 I 1954114 1,91 01n C:yh1~n T~kJH('\rA~'7Al1 JcLI12533 William Scamooli 12 103. I 19731 4 11 (1/ [..Th; rp Pnnn Rn~~c:rnrTm1j 11 e I ] 2582 - -- I I I '_1_1_' I 1_1_1_1 I , 1_1_1_' I II ,I 1_1_1_1 1 I I 1_1_1_1 I SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES (MAXIMUM OF 2 AUXll..IARIES/ AFFll..IA TES, EACH AUXll..1ARY/ AFFll...IATE LISTED MUST HAVE ITS OWN ID NUMBER.) NAME OF AUXILIARY/AFFlLIATE GAMES OF CHANCE ill NUMBER L BJ-GC-2A (Rev. 4/03) Page 1 of2 1111/11 11111 11111111I11111111 ~ r' " . GC-2B 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-rn-~-~-~ NYS Identification Number [I]/DJ/DJ Date SCHEDULE 5 DATES, HOURS AND RENT OF ALL LICENSE PERIODS TO BE HELD (NOT APPLICABLE FOR BELL JAR. GAMES) DATE HOURS RENT . /. , /. I am /pm - .am/pm ! $. , , . . . . . . I ,., , . /. , / , I am/pm - .am/pm!$ , . . . . . . . . . . . . , / ,. . /. I am / pm - ,am / pm $, . , . . . . . . . ,., . /. . /. I am / pm - ,am / pm $. . . . . . . . . . ,-, . / , . /. I am / pm - am / pm $. , , , . . . . . . . . . . . . / . , / , I am / pm - am / pm $. . , . . . . . . . . . . , . / . , / . I am / pm - am / pm $. . . . . . . . . . . . . . . / . . /. I am / pm - am / pm $. , , . . . . o. . . ,-, . / . . /. I am / pm - .am / pm ,$ , , , . . . , o. . . . . . / . , /. I am / pm - ,am/pm! $. . , . . . . . . . . ,., . / . . / . I am / pm - ,am/pm! $. . , , . . . . . . . ,., . /. , /. I am / pm - ,am/pm!$ , , . . . . . . . . . . . RAFFLES PRIZES (Cash or Fair Market DATE TIME Value of Merchandise) . /. ./ I am / pm - am / pm !$, . I . . . . . . . . . , . . , . . . , . / . ./ I am / pm - am / pm !$. . I . . . . , . . . , . . . . / . . / . I am / pm - am / pm !$. . I . . . . . . . . . .., . / . . / . I am / pm - am / pm !$. .1 . . . . . . . . . .a, . / . ./ I am/pm - am / pm !$. . I . . . . . . . . . . . SCHEDULE 6 EXPENSES List it~ms 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. 4/03) Page 1 of2 11111111111111111111111111111 --.J '.r" ,GC-2A APPLICATION FOR GAMES OF CHANCE LICENSE 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 -, Name of Organization GC- rn - @ill- EEEJ - ~ NYS Identification Number SCHEDULE 1: ' 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 CITY ZIP President I William Scampoli I..1LI ~I 19731162 White Pond I Stormvillel12582 Treasurer I Floyd Scholz IJliLI ~I 1952/25 Clover Hill I Poughkeeps~e12603 Secretary I Paul Taesatano I~I ~I 195~338 Cary Road I Fishkill 112524 Director I Bill Hunt I.-JJLI 2!LI .l91U1109 Ja~kso~ S't. / Fi ghkil1 11 ? S?4 Director I Peter Cassidy 1....Q!z..1 O!l-I llQ5151 Orchard P1ace~opewel] Jcb. 12S1.1 Director "I Jerry Albanese I~I ~I 1957/52 Hemlock DrivelHopewell Jc~ .12533 Director, I Wa1'ly Wych 1~/~/195~193 Old Sylvan rJakeHopewell/ Jct12533 I 1_1_1_1 I I I 1_1_1_1 I I I 1_1_1_' I I I 1_1_1_' I I Attach additional sheet if necessary. [D/OJ/CD Date OFFICERS AND DIRECTORS SCHEDULE 2: MElY.IBERS IN CHARGE OF GAMES (MUST LIST AT LEAST FOUR MEMBERS OF APPLICANT ORGANIZATION) DATE YEARS OF , NAME ,OF BIRTH :MEMBERSHIP STREET ADDRESS CITY ZIP Peter Cassidy I 04 109 1 19651 21 I 51 Orchard Place IHopewell J~t 11 ?S11 Floyd Schol z 1-08 I 0;;- / 19521 29 r 25 Clover Hi 11 Dr IPnllgnkppp~ i p 11 ?('O'i Wally Wvch I 09/03 / 1954114 11q1 01rl ~y1"::In T.<I~JJ-TorE>T'7P]1 Jct./11533 William Scampoli! 12/03, / 1973/ 4 11n2 t.vnit'p Pnnrl Rn::lrlISrn"rnmil1E> I 12582 1=/=/_1 I I I 1_/_1_1 / I I '_1_/_' I 1_/_/_' I I I 1_/_/_1 I I I SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES (MAXlMUM OF2 AUXILIARIES/AFFILIATES. EACH AUXILIARY/AFFILIATE LISTED MUST HAVE ITS OWN ID NUMBER.) NAME OF AUXILIARY/AFFILIATE GAMES OF CHANCE ill NUMBER L BJ.GC-2A (Rev. 4/03) Page 1 of2 11111111111111111111111111111 -.J .,. ,. r GC-4 NYS RACING & WAGERING BOARD 1 Waterv1iet Ave. Ext., Suite 2 Albany, NY 12206-1668 Telephone (5 18) 453-8460 Fax (518) 453-8492 www.racing.state.ny.us FINDINGS AND DETERMlNA nON FOR GAMES OF CHAN'CE LICENSE -, ITrn - [Q]2lili[1J GC - []I] - [liI2J - N.Y.S. Identification Number Town of Wappinger Name of Municipality e Name of Applicant Organization 339 Route 82, Wappingers Falls, NY 12590 o 7 Municipal License Number Dutchess Address After investigation, and a hearing ifrequired 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 ap . character and have never been convicted of a Signature of Person Conducting Investigation' s of chance are of good moral tlYes DNo 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) KJ Yes DNo lXI Yes DNo .Kl Yes DNo Kl Yes DNo fI Yes DNo KI Yes DNa KJ Yes DNo Kl Yes DNo DYes DNo TO BE COMPLETED BY MUNICIPAL CLERK: As a result of the findings and determinations stated above, license is GRANTED ~ense is DENIED 0 Signature of Filing date of Application Authorized Officer Dare ~ ~7- Title IO<J" 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-4 (Rev. 4/03) "11""11 11111111111111I 1111 ..J r GC-5 LICENSE TO CONDUCT GAMES OF CHANCE PLEASE CHECK GAMES OF CHANCE 0 BELL JAR XX RAFFLE 0 GC-[LGJ- ~-lLGLJ- ~ 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 $/ 25 .00 II Amount of Fee Paid Lessor's License Number Address; 339 Route 82 City; Wappingers Falls Entire net proceeds to be devoted to the following specific lawful purpose(s): Zip Code; 12590 Names of Members in Charge Peter Cassidy Floyd Scholz Wally Wych William Scampoli LICENSE PERIOD DATE DAY OF WEEK HOURS TYPE(S) OF GAMES Year 2007 RAFFLE DRAWING DATE DRAWING 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 $ NUMBER OF GAMES THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED FOR EACH MERCHANDISE WHEEL $ EACH GAME (Starting Bank) NUMBER OF WHEELS EACH WHEEL THE TOTAL AMOUNT OF PRIZES FOR EACH BELL JAR DEAL SHALL NOT EXCEED $3,000 AND NO SINGLE PRIZE SHALL EXCEED $500. GAMES SHALL BE PLAYED IN ACCORDANCE WITH STATE LAWS AND RULES AND LOCAL ORDINANCES OR LAWS. Issued by Tnwn nf W~p;nfPr ( ame 0 Municipality) (Date) Town Clerk (Title of Authorized Officer) (J~('q::7C ~ ?J ("alure of Autho~lm liliii I DIIIIII ..J L BJ-GC-5 (Rev. 3/06) .:'... .. I GC-2 --, NYS RACING & WAGERING BOARD I Watervliet Ave. Ext., Suite 2 Albany, NY J2206-1668 Telephone (518) 453-8460 Fax (5] 8) 453-8492 www.racing.state.ny.us APPLICA TION FOR: PLEASE CHECK GAMES OF CHANCED (Casino Nights, Bazaars, Carnivals) BELL JAR ~ RAFFLE 0 (only raffles wI over $30,000 net profits in calendar year) FOR OFFICE USE ONLY $1 ?"i 00 Fees Received GLJjQJ/rn Date INSTRUCTIONS: PLEASE FILE THREE SIGNED COPIES WITH MUNICIPALITY GC - [ill] - [ilill- [Uill- ~ N.Y.S. Identification Number IT IS A MISDEMEANOR TO MAKE ANY FALSE STATEMENTS IN THIS APPLICATION Town of Wappinger Dutchess Name of Municipality County 2. Address 339 Route 82, Wappingers Falls, NY 12590 3. Has applicant ever been denied a games of chance license? 0 Yes Kl No If "yes", why? (Attach extra sheet if necessary) 4. Check type of organization and, if applicable, give the State and date of incorporation. Corporation [X State incorporated New York Incorporated Association 0 Unincorporated Association 0 State incorporated Date [IJ / [IJ / rn Date [IJ / [IJ / [IJ Individual o 5. Did your corporate status change since your identification number was assigned? 0 Yes 0 No 6. Are you doing business under a trade name? 0 Yes fiNo If "yes", what is the trade name? PART B. LOCATION OF GAMES 339 Route 82 7. Address where games, bell jar, orraffle drawing(s) are to be conducted. Wappingers Fall s, NY 12590 8. Name and address of authorized games of chance lessor renting to applicant. 9. Does the applicant own the premises? UYes 0 No If "yes", how long? 10. Capacity for public assembly of premises presently owned or occupied. 250 11. Have premises been regularly used?ftYes 0 No If "yes", how long? 1970 Are games of chance being played now on these premises or has it ever been? 0 Yes 0 No If "yes", give full details. 12. Are the premises or any part thereof where games of chance are to be played licensed by the State Liquor Authority? ID Yes 0 No If "yes", state the type of license and number. on gremises liquor license 2 03-2 D'ltches<; ')1<' 510252 13. Has such license ever been If "yes", why? (Explain on a separate sheet, if necessary, and attach.) revoked or suspended? 0 Yes kI No L BJ.GC.2 (Rev. 4/03) Page 1 of2 11111111111111111111111111111 ~ .'i I PART C. PURPOSES OF GAMES ]4. State the specific purposes for which the entire net proceeds are to be devoted and in what manner. charity, patriotic, youth, educational I I swear (or affirm): ]. 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 "lawfu] 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 Ru]es 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 rcsponsible for the holding. operation and conduct of all games of chance in accordance with the terms of the license, the provisions of the Games of Chance Licensing Law, the Ru]es and Regu]ations 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 th ames of Chance Licensing Law as amended. the Rules and Regulations of the N.Y.S. Racing & Wagering Board. and the local licensing or nances JrTaws. 6. That no commission, salary. compensation, reward or reeo pjmse will b aid to any person for holding or assisting in the operating or conducting of the games, except to bookkeepers c n~ts for pr iona] services in an amount not exceeding that fixed by the Board. [][[] / OJ] / (ill] Date STATE OF NEW YORK }ss COUNTY OF Dutchess CITYffOWNNILLAGE OF Wappinger 1A)(LU.4A-1 Print Name ~CAM?{) L l Will iam Scampol i 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 J 1~/~ day oflih\,Huy _Mct0t Ann ~ . Notary Public My Commission expires ~ c"'y 2, '1 .20R S;gned ~)~~~~Jd~}LL Commissioner of Deeds 20 Of '- (, _AIl'l ANN II;;INOU" NO'.', Public, .,.,. of N.", '10,11 No. .f_CJ'71J1. Q..,,"." ,,, ".'c"... Co.''" Co..,,,,.,, ..",.. '''2'' C i L BJ-GC-2 (Rev. 4/03) Page 20f2 1111111111111 111111111111111 .J .'i . . . .r" o 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-rn-0TI-EGD-~ NYS Identification Number SCHEDULE 1: . OFFICERS 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 CITY ZIP President I William Scampoli l..lLhU_1 19731162 White Pond I Storrnvillel125R2 Treasurer I Floyd Scholz I....QJL.I Q.2.-1 1952125 Clover Hill I Poughkeeps~e 12603 Secretary 1 Paul Taesatano 1~/~/195~33R Cary Road I Fishkill 112524 Director I Bill Hunt I-1.Q....I 2iLI .l.9A21109 Jackson S't _ I Fi snki11 I, ?S?4 Director I Peter Cass idv I.!1!:LI D!L-I .l2..6..5151 Orchard Place~opewe 11 Jc~ _ 121)11 Director "1 Jerry Albanese 1.!J2.1'!:!!..-/1957152 Hemlock Drive~Iopewell jct.12533 Director. I Wal'ly ~-lych I-9.:LI.QL/195~193 Old Sylvan UakeHopewelll Jct12533 I 1_1_1_1 I I I 1_1_1_1 I I I 1_1_1_' I I , 1_1_1_1 I I Attach additional sheet if necessary. OJ/m/OJ Date SCHEDULE 2: MEMBERS IN CHARGE OF GAMES (MUST LIST AT LEAST FOUR MEMBERS OF APPLICANT ORGANIZATION) DATE YEARS OF , NAME OF BIRTH MEMBERSHIP STREET ADDRESS CITY ZIP Peter Cassidy I 04 109 I 19651 21 I 51 Orchard Place IHo1)ewe 11 .Jet .1, / '111 Floyd Scholz I --os I ~ I 19521 29 I' 25 Clover Hi 11 Dr IPnllEnkppp~i p I, ?h01 vJallv Wvch I 09/03 I 1951fll4 1,91 Olrl ~yhnm T~kJJ-Tnr':>T'T.:>ll 1ct.112533 William Scampo1il~/~1 19731 4 Iln? l.Jnit"p Pnnrl R():H'~Srnrm'dll.:> I ]2582 1_1_1_1 I I I '_1_1_1 I I I 1_1_1_1 I I I I I / I I I I 1=1=1=1 I I I SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES (MAXIMUM OF2 AUXILIARIES/AFFILIATES. EACH AUXILIARY/AFFILIATE LISTED MUST HAVE ITS OWN In NUMBER.) NAME OF AUXILIARY/AFFILIATE GAMES OF CHANCE ill NU:rvIBER L BJ.GC.2A (Rev. 4/03) Page 1 of2 11111111111111111111111111111 --.J ~.. .- ~. . r GC-2B 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 I GC-rn-~-~-~ NYS Identification Number [[J/[[J/[IJ Date SCHEDULE 5 DATES, HOURS AND RENT OF ALL LICENSE PERIODS TO BE HELD (NOT APPLICABLE FOR BELL JAR, GAMES) DATE HOURS RENT . I , . I. I am / pm - .am /pm ! $ , , . . . . . . . . ,-. , I , . I , I am / pm - .am /pm 1$ . , , . . . , . . . 1-' . I " . I . I am / pm - .am /pm $, , , . . . . . . . . . . , I. , I. I am / pm - ,am / pm $. . , . . . . . . . . . . , I , . I . I am / pm - am / pm $. , , . .. . , . . . . 1-' . I , , I , I am / pm - am / pm $. , . . . . . . . I . . . . . . I . , I . I am / pm - am / pm $, . . . . . . . . . . ,-, , I , ,I . I am / pm - .am /pm $, . . . . . . . . . 1-' . I , . I. I am / pm - ,am/pm $, , , , . . . . . . . 1-' , I , . I , I am / pm - am / pm $, , , . . . . . . . , 1-' . I , , I . I am / pm - ,am / pm $. . , , . . . . . . . 1-' , I . , I , I am / pm - ,am /pm $, , , . . . . . . . ,-, RAFFLES PRIZES (Cash or Fair Market DATE TIME Value of Merchandise) I. I I am / pm - am / pm !$, . , I . . . . . . . . , , . , , 1-' , , I. . I . I am / pm - am / pm !$, . I . . . . , .. . . . . . I. . I , I am / pm - am / pm !$. . I . . . . . . . . . ,-, , I , .1 I am / pm - am / pm !$. . . I . . . . . . . . . 1-' , I , , I . I am / pm - am / pm !$. . I . 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 STATE ZIP L BJ-GC-2B (Rev. 4/03) Page 1 of 2 11111111111111111111111111111 .J r GC-4 NYS RACING & WAGERING BOARD ] Watervliet Ave. Ext., Suite 2 Albany, NY 12206-1668 Telephone (5] 8) 453-8460 Fax (518) 453-8492 www.racing.state.ny.us FINDINGS AND DETERMINA nON FOR GAMES OF CHANCE LICENSE GC-CTIIJ-~-~-~ N.Y.S. Identification Number Town of Wappinger Name of Municipality I Address NY 12590 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 ap . character and have never been convicted of a 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 win 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) f/Yes DNo fJ Yes DNo !XI Yes DNo XJ Yes DNa Kl Yes DNo ID Yes DNa Kl Yes DNa fJ Yes DNo KJ Yes DNo DYes DNo TO BE COMPLETED BY MUNICIPAL CLERK: As a result of the findings and determinations stated above, license is GRANTED ~ense is DENIED 0 Signature of Filing date of Application Authorized Officer Da", ~1~{<17- Titl, IfNn 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 ~ev. 4/03) 11111111111111111111111111111 -.J .