Knights of Columbus
TOWN OF WAPPINGER
TOWN CLERK
CHRIS MASTERSON
TOWN CLERK'S OFFICE
20 MIDDLE BUSH ROAD
WAPPINGERS FALLS, NY 12590
(845) 297-5771
FAX: (845) 298-1478
January 3rd, 2007
New York State Racing and Wagering Board
1 Broadway Center, Suite 600
Schenectady, New York 12305-2553
Subject:
BELL JAR LICENSE - Knights of Columbus #1646 - 2007
Please find enclosed the GC-2, GC-2A, GC-4, and GC-5 for the Knights of
Columbus #1646 for the year of 2007.
SUPERVISOR
JOSEPH RUGGIERO
TOWN COUNCIL
WILLIAM H. BEALE
VINCENT BETTINA
MAUREEN McCARTHY
JOSEPH P. PAOLONI
DUTCHESS COUNTY SHERIFF'S OFFICE
Criminal Records Bureau
Poughkeepsie, New York
Phone: (845) 486-3810
Fax: (845) 486-3853
Memorandum
To:
Knights of Columbus #1646
Jodi Clark, Program Assistant CJI
December 28, 2006
From:
Date:
Subject:
Games of Chance
Recently this office has received an application for games of chance.
The lists of members in charge of games were hand written and as a result hard
to read. Please c1earlv print these names on future applications, or attach a typed
list of names.
Names checked: James O'Connor
John Gorman
John Simmons
Max Dao
Also, please use the members FULL NAME, we cannot assume that Rich, or
Dick should be - Richard.
Thank you, your cooperation is greatly appreciated.
If there are any questions please call me at the number above.
./'
"
,-
,GC-2
--,
NYS RACING & WAGERING BOARD
] WatervIiet Ave. Ext., Suite 2
Albany, NY 12206-]668
Te]ephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
APPLICATION FOR:
PLEASE CHECK
GAMES OF CHANCE 0
BELL JAR ,JiY
RAFFLE 0
FOR OFFICE
USE ONLY
$1 Jr,OV I
Fees Received
waJ/IJlol/~
Date
INSTRUCTIONS: PLEASE FILE THREE SIGNED copms WITH MUNICIPALITY
GC-rn-~-[ilQIIJ- ~
N.Y.S. Identification Number
IT IS A MISDEMEANOR TO MAKE ANY FALSE STATEMENTS IN THIS APPLICATION
--tc:, LN r-J ~ -r v.J 0.. f f ,'", ~ e R... UvI. +ck e ,S" (
Name of MunicipalityCounty
PART A, GENERAL
1. Name of Or anization
F Co 10
2. Address b ~s -\- fflo.... \ r.::> :z. .J" W ~f) f 1',..., J P R.
3. Has applicant ever been denied a games of chance license? D Y~s JilNo If "yes", why?
y
(Attach extra sheet if necessary)
4. Check type of organization and, if applicable, give the State and date of in corporation.
Corporation 0
State incorporated
Incorporated Association 0
Date[TI/[D/[D
Date[TI/[D/[D
Unincorporated Association 0
State incorporated
Individual
o
5. Did your corporate status change since yourjdentification number was assigned? DYes D No
- '-" fVVtf Y;~ .
6. Are y'Cfu'doi'ng business under a trade name? D Yes r,fNo If "yes" ,what is the trade name?
PARTB. LOCATION OF GAMES /"
7. Address where games, bell jar, or raffle drawing(s) are to be conducted. 2 bt:tj + (y) Ci ~ ~ CS+
(A) 1=. N Y
8. Name and address of authorized' games of " .
chance lessor renting to applicant.
10(A
<'.-.
9. Does the applicant own the premises? , Yes . D No If "yes", how long?
1 O. Capacity for public assembly of premises presently owned or occupied.
11. Have premises been regularly used? ~ Yes 0 No If "yes", how long? L{ () y{S
Are games of chance being played now on these premises or has it ever been? @"Yes DNo If"yes", give full details.
dO yr)
12. Are the premises or any part thereof
where games of chance are to be played
licensed by the State Liquor Authority?
1,i1 Yes DNa
If "yes", state the type of license and number.
C L ,~~
;;L\.f3
13. Has such license ever been 0
revoked or suspended? Yes
ptNo
If "yes", why? (Explain on a separate sheet, if necessary, and attach.)
L BJ-GC-2 (Rev. 4/03)
Page I of2
1111111111111111111 " /1111111 ~
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PART C. PURPOSES OF GAMES
14. State the specific purposes for which the entire net proceeds are to be devoted and in what manner.
G f \J e t 0 U 'L ~ \' lJ '""- <; L ~ c... {{ ( \-~ " s
I swear (or affirm):
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 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 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 Board.
[l]1l/ [QG] / 101 hi e/
Date
STATE 0 NEW YORK }ss
COUNTY OF 'i>u rr/>>c$~
CITYITOWN/VILLAGE OF \(6U61~ ~ffi>~/E
.::fa .' being duly sworn deposes and says that ~he is the person above named,
that .)he has rea the foregoing statement and the answer therein noted, and that such answers are true and that ~he has personally
affixed his ~) signature to this affidavit.
Sworn to before me this 3Rt
tsf.20 ef p,~~,Jru
Notary Public
My Commission expires I {( . J rn
day of P~Br;~ , 20 {)lp
,
Signed ?fun. R r
Commissioner of Deeds
,20 It
BRUCE PISANO
Notary Public, State of New York
01 P14975784 ou!chess County
Commission ExpIres t ~'2(p..2f)~"
L BJ.GC.2 (Rev. 4/03)
Page 2 of2
1111111I1111111111I1111111111 .J
r-~
,GC-2A APPLICATION FOR GAMES OF CHANCE LICENSE
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
1< tv i C, It r s
Name of Organization
GC-rn-~-~-~
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 unincOlJlorated association, list officers and directors.
TITLE NAME DATE OF BIRTH STREET ADDRESS CITY ZIP
(~RI\...l K ,..,.~t.~1 J~t.r..N (2./" -e+,..:>"R. I~I .3.CfI fL I q c:/~' L.t1, hli'H 7:-w IlJJc..J?f r; {L, I 12.\.S-q.6
Dr ~c,;vd l{'r--> .", (Jilt u e B Ro~~ L}:LI ~I k..L I :l. 5- .I,..~..!" PtU'f I ~!.~, ~Sl" /1 z." 6.1
C.~4"'CA'lo R I Rlc.l< [/C\-" tJ()5t-~'" I~I 1::..LI J-s- I SID fY!.4/01V? {(J.... I ev~ (~'1.st-e I /2I.o?
R~c.a(tJ~!'?- I n.~\< f) IVI'kH~ I~I ~I 3 71s-<t. S.}')1~!>\<!1( ACId Oi..'AfO G7rJel/2.S'lo
T(,~4S('{R'PR..1 r\tt...'f ~~O II ?_I ~I b"'3.1 2. OV:OVl"R LN I~I {2.S-'To
./l-J.//o c....+~ ., l.~ /{t I LlI -D-.I ~ I q ( ;-1,/1, ~ ~R!? I {~~ 1/1(.,.(3-3
-+ rL>~~ I I~I ~I E.L I S- 'J{.t"" I IN D IL I {A11 NiL IIL~-'Ln-
1 ("s1---"- I I ( >-/ Q.J...... / c, b I' &' :;, /VI", <J< ~ <'( I lP"f12 bJU I I L:,:'l C>
-+("sf~ e I i '2.. ~ L.o ~ /Po i II. ~r..JI..4 ,j., I~ ~ 112S"lO
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Attach additional sheet if necessary.
OJJJ 1 ~ 1 /D/ GI
Date
SCHEDULE 2: ME:MBERS IN CHARGE OF GAMES
(MUST LIST AT LEAST FOUR MEMBERS OF APPLICANT ORGANIZATION)
DAlE YEARS OF
NAME . OF BIRTH MEMBERSHIP STREET ADDRESS CITY
Jo..M.(? <. 0' C14-~ 1--11- 1 -2.s:. 1 ..:iL I f)....if 1._1, 1+ t~ '-. c..+ , l}.::)~ ~~
~~ok~ Gbe(",-o.-~I3-1 ~o 1 5-2/ [q , L 1;) ~V~4 0/<... I w1)9 ~
~I..," !;. ~'" 0 '-'-' I -1L / ..J..L / ..L'L I ? I I $'"'1 iH IS" >0 glll.{ I W'J/ I ~.d, I
-"-t [to iE::;~-3.l-~ Pi S i 2 D~y~R 1..-4__ : w~' M~I
'-1-1-' II
'=1=/=1 I I
I 1 1 I I I
1=1=1=' I I
ZIP
, Z :)<1-0
1 2.~-~ 0
I 1_::)~ 0
I ~ 5"'96
SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF 2 AUXll..IARIES/AFFll..IATES. EACH AUXll..IARY/AFFILIATE LISTED MUST HAVE ITS OWN ID NUMBER.)
NAME OF AUX.IT.JAR Y/ AFFILIATE
GAMES OF CHANCE ill NUJ\.1BER
L BJ-GC-2A (Rev. 4/03)
Page 1 of2
11111111111111111111111111111 --.J
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r SCHEDULE 4: ASSISTANTS TO MEMBERS IN CHARGE OF GAMES --i
List all members of applicant organization and members of authorized affiliates and auxiliary who will assist with games. Each person listed must he a
member of applicant organization or affiliate for at least 1 year.
YEARS OF
MEMBER NAME . DATE OF BIRTH MEMBERSHIP STREET ADDRESS
1_1_1_1_1 I
1_1_1_1_1 I
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 I
1_1_1_1_1 I
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 I
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 I
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 I
1_1_1_1- ~ !
I_~_/_I_I _I
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1_/_1_1_1 I
1_/_1_"'_1 I
1_1_1_\u_1 I"
1_/_1_1_1 I
1_/_1_1_1 I
1_/_1_1_1 I
1_/_1_1_1 I
1_/_1_1_1 I
CITY ZIP
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L BJ-GC-2A (Rev. 4/03)
Attach additional sheet if necessary.
Page 2 of 2
r
, GC-2A
-,
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
/< N i c, If r So
Name of Organization
GC- rn - I1IJEJ - ~ - ~
NYS Identification Number
SCHEDULE 1: OFFICERS AND DIRECTORS
List names, addresses and dates of birth of all officers.
If organization is a cOlJloration, or an incolJlorated or unincolJlorated association, list officers and directors.
TITLE NAME DATE OF BIRTH STREET ADDRESS CITY ZIP
(~RAr~~ I( p..>.~L-(.1 ~n~N L~ <e+~"R. I..LI .Q.'f 1 ll.1 q Eft' 1-", h'H f,{fi IW"'flf r; t L I J 2~-~
D~~~dl<I'-',~,1 Ol\ue BRol".,.r-:> I.-::L/~/!LL"..)-..I,...~"~ A-U'f I ~!~'~Str. ItZ.t:.6J
c..~'4""'CA'lo{( /RIc.I< [/4.- tJost-ro.....I-1LI.1::..L1 ss-lslo ~/olV'7 ReA.... IfL~(k->1'.sI-e1/2{'O?
R~'-o({Jen. I 0[,<:-\< fllvl~'e I~I ~/:? 7/S-lf. S'~l'l.\ot.f( A"d OJ..Jc'fu!7rJ.eI/1SQO
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-f rLJ ~ ~ I 1-3- 1 P..:L 1 E.L Is- ~ t{'lrlol I. N D R - I <:::tr ~. I I i..6-'t-tr
-f(u~~--"- I I f)-I QLI (" b I 'b' ~, /Vl",<,< ~Q{ I LO"/r'~ I 12;,'\0
+fuS+., e I 1~/4.0 1 (Po lICe. fJnv~cJU,.. ). I~ ~ 1/2S9.0
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Attach additional sheet if necessary.
[ill 1 ~ 1 I()/ GI
Date
MEMBERS IN CHARGE OF GAMES
(MUST LIST AT LEAST FOUR MEMBERS OF APPLICANT ORGANIZATION)
DAlE YEARS OF
NAME . OF BIRTH MEMBERSHIP STREET ADDRESS
J~M.~<' c5 CU-IlA~ 1-1..L 1 -2L. 1...iL1 f)....l/J 1,.i:::.H-I?, ~ ~+
~\t>k~ GD fJJ,...o--~ I ~ 1 'd..-O 1 .s ..21 { q I L b ~v~ 4 0 f(.
it'" ~ ~"'.....-" 1-11.JJJ~..J ~I ? I I S-I iH ~">Q (S1'1.{
!:LA: D 0 1...l3= 1 ..3.4- 1 b ~ I s I :2 OVJ->1'" ~ L- ~ ^"'...
, I 1 1 I I
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CITY
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ZIP
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SCHEDULE 2:
SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF 2 AUXILIARIESI AFFfLlA TES. EACH AUXILIAR YI AFFILIATE LIS1ED MUST HA VB ITS OWN ID NUMBER.)
NAME OF AUXILIARY/ AFFILIATE
GAMES OF CHANCE ill NUMBER
L BJ-GC.2A (Rev. 4/03)
Page 1 of2
11111111111111111111111111111 --1
r SCHEDULE 4: ASSISTANTS TO MEMBERS IN CHARGE OF GAMES I
List all members of applicant organization and members of authorized affiliates and auxiliary who will assist with games. Each person listed must be a
member of applicant orl!;anization or affiliate for at least 1 year.
YEARS OF
:MEMBER NAME . DATE OF BIRTH :MEMBERSHIP STREET ADDRESS
1_1_1_1_1
1_1_1_1_1
1_1_1_1_1
1_1_1_1_1
1_1_1_1_1
1_1_1_1_1
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1_1_1_1_1.
I 1 1 I_I
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1_1_1- _I
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1=1=1= I - 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_1
1_1_1_1_1
1_1_1_1_1
1_1_1_1_1
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--- -'-
1_1_1_1_1
1_1_1_1_1-
1_1_1_1_1
1_1_1_1_1
1=-/ _/~I - 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_1
CITY ZIP
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L BJ-GC-2A (Rev. 4/03)
Attach additional sheet if necessary.
Page 2 of 2
r
GC-4
NYS RACrNG & WAGERING BOARD
I Watervliet Ave. Ex!., Suite 2
Albany, NY 12206- 1668
Telephone (5 18) 453-8460 Fax (518) 453.8492
www.racing.state.ny.us
FINDINGS AND
DETERMINATION
FOR .GAMES OF CHAN'CE
LICENSE
I
GC - [!Ii] ~ WiliJ - GIiI!J - ~ .
N.Y.S. Identification Number
Town of Wappinger
Name of Municipality
Falls. New YOTK 12590
After investigation, and a hearing if required under Sec. 192 of the
have been made:
1. All the members-in-chargedesignated in the a 0 No
character and have never been convicted cri
Signature of Person Conducting Investigati Title
2. Applicant is a qualified authorized organization as defined i
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 La be paid to an authorized games of chance lessor is reasonable.
10. Other findings: (Specify)
on Yes DNo
Kl Yes DNa
Kl Yes DNo
IJ Yes DNo
~Yes DNo
iI Yes DNo
ag Yes DNa
il Yes DNa
iI Yes DNo
TO BE COMPLETED BY MUNICIPAL CLERK:
As a result of the findings and determinations stated above, license is GRANTED ~cense is DENIED 0
Signature of
Filing date of Application Authorized Officer
Date ~ r) 7 Title
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) 1111111111 11111I11111111I 1111 --.J
I
GC-5
LICENSE TO CONDUCT
GAMES OF CHANCE
PLEASE CHECK
GAMES OF CHANCE 0
BELL JAR fk
RAFFLE 0
GC-Q- m=J- GLJJ- ~
N.Y.S. Identification Number
$1 $7<; 00 II I
Amount of Fee Paid Lessor's License Number
--,
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
This License Must Be
Conspicuously Displayed
During Conduct of Games
Municipal License Number
The following organization:
Address: 2 East Main Street CitY:Wappingers Falls, NY
Entire net proceeds to be devoted to the following specific lawful purpose(s):
Give to various charities
Names of Members in Charge
James O'Connor
Zip Code: 12590
John Gorman
John Simons
Max Dao
LICENSE PERIOD
DATE
Year 2007
DAY OF WEEK
HOURS
TYPE(S) OF GAMES
RAFFLE DRAWING
DATE
DRAWING TIME
DRAWING LOCATION
AMOUNT OF RAFFLE PRIZES (Cas~ or Merchandise Prizes
at FlIIr Market Value)
THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
FOR EACH TYPE OF GAME OF CHANCE
$
THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
FOR EACH MERCHANDISE WHEEL
$
NUMBER OF GAMES
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
~t'\ 6f wfl(Jo IN(,.(.'L
(Name of Municipality)
Ol!~ v'1
( ate)
ure of Aut 0 zed Officer)
11111111111111111111111111111 -.I
L BJ -GC-5 (Rev. 4/03)
"
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
VINCENT BETTINA
MAUREEN McCARTHY
JOSEPH P. PAOLONI
ROBERT L. VALDATI
December 20th, 2006
Adrian Anderson, Sheriff
150 North Hamilton Street
Poughkeepsie, New York 12601'
Dear Sheriff Anderson:
Enclosed, please find a copy of the "Members in Charge" of Knights of Columbus,
#1646,2 East Main Street, Wappingers Falls, who will be selling BELL JAR tickets
on their premises throughout the year 2007.
I would appreciate your review of the application and then would you please
complete the "Findings and Determination" form attached.
Thank you for your attention to this request and your prompt reply.
Yours truly,
2f.~~
Town Clerk
Town of Wappinger
I
GC-4
NYS RACING & WAGERING BOARD
] Watervliet Ave. Ext., Suite 2
Albany, NY 12206.]668
Telephone (5] 8) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
I
FINDINGS AND
DETERMINA TION
FOR GAMES OF CHANCE
LICENSE
GC - [ili]~ ~ - GIQLJ - ~.
N.Y.S. Identification Number
Town of Wappinger
Name of Municipality
Falls. New York 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 application to conduct games of chance are of good moral 0 Yes 0 No
character and have never been convicted of a crime. .
Signature of Person Conducting Investigation
Title
2. Applicant is a qualified authorized o~ganization 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)
[I Yes DNo
IJ Yes DNa
IJ Yes DNo
mYes DNo
~Yes DNa
iI Yes DNa
~Yes DNa
iI Yes DNa
iI Yes DNo
TO BE COMPLETED BY MUNICIPAL CLERK:
As a result of the findings and determinations stated above, license is GRANTED 0; license is DENIED 0
Signature of
Filing date of Application 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-GC4 ~ev. 4/03) 1111111111111111111111111 1111 -.J
. BELb~AR~~GAM~s OF,OHA"'OE .
WAPPIN(;ERSGOUNGlb:KOF G 1646,
!~6
FOR . . ., .
:"1:0 2BOO ~OB.~I=dB 2 'i' 5 51 22111
~(..
4/1Jjit1r..
1-108/280
$1 ).s:-url
DOLLARS
~JI(l~
~~,.....,..,
022"5
--..
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
APPLICA TION FOR:
PLEASE CHECK
GAMES OF CHANCED
BELL JAR )i!1'
RAFFLE D
-,
.
'...
r
,GC-2
FOR OFFICE
USE ONLY
$1 J)",OV I
Fees Received
CLIaJ I IJ 10 I / [QQ
Date
INSTRUCTIONS: PLEASE FILE THREE SIGNED COPffiS WITH MUNICIPALITY
GC- [il3]- ~- [I[QIlJ-~
N.Y.S. Identification Number
IT IS A MISDEMEANOR TO MAKE ANY FALSE STATEMENTS IN THIS APPLICATION
-tc, ~ rJ c..(2 v-Ja. f f I "'~ e R- UvI.. +cke 5' (
Name of MunicipalityCounty
PART A. GENERAL
1. Name of Or anization
1 k+ s 0 F ItJ tAS
2. Address 2.. b o\..s -\- fYl",- t ~ ~ .J" l..0 C\.f f t N J P R /=a../I..s (\J y
3. Has applicant ever been denied a games of chance license? DYes )lNo 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
State incorporated
Incorporated Association 0
Unincorporated Association 0
State incorporated
DateD/CD/CD
DateD/D/CD
Individual
o
5. Did your corporate status change since your.ldentification number was assigned? 0 Yes D No
- '-" f vV' / II ,:-""
6. Areytfu'doi'ng business under a trade name? 0 Yes r,tNo 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. 2 EA.~ + (Yl a. ~ N CS+
(A.) 1=. N Y
8. Name and address of authorized' games of
chance lessor renting to applicant.
f\J ( J~
9. Does the applicant own the premises? W Yes .0 No If "yes", how long?
10. Capacity for public assembly of premises presently owned or occupied.
11. Have premises been regularly used? III Yes 0 No If "yes", how long? L{ () yiS
Are games of chance being played now on these premises or has it ever been? GrYes UNo If"yes", give full details.
dO yr)
12. Are the premises or any part thereof
where games of chance are to be played
licensed by the State Liquor Authority?
~Yes ONo
If "yes", state the type oflicense and number.
C l . ~'t
;;L~3
13. Has such license ever been D
revoked or suspended? Yes
f1J No
If "yes", why? (Explain on a separate sheet, if necessary, and attach.)
L BJ-GC-2 (Re". 4/03)
Page 1 of2
11111111111111111111111111111 ~
'-
I
-,
PART C. PURPOSES OF GAMES
14. State the specific purposes for which the entire net proceeds are to be devoted and in what manner.
G f \J e t 0 U D- R " () -....... S C ~ c-. ~ ( \-1' ' .s
I swear (or affirm):
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 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 garnes.
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 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 Board.
[ilil/ [QG1 / \DI hi ,.--- eI
'--'
Date
STATE 0 NEW YORK }ss
COUNTY OF ~ 'i(~~cS~
CITYrrOWNNILLAGE OF ?DU61~ r)fff>.:5/E
..::yo a~c7/t1rR.. . being duly sworn deposes and says that ~)he is the person above named,
that {II)he has rea the foregoing statement and the answer therein noted, and that such answers are true and that ~he has personally
affixed his <iwf) signature to this affidavit.
Sworn to before me this 3'Rb
~(.(0 ef ~~,A-,Jru
Notary Public
My Commission expires 1 R . J fA
day of P~B~ , 20 Olp
-
Signed
?Juw
f<r
-
Commissioner of Deeds
,20 It
BRUCE PISANO
Notary Public, State of New York
01P14975784 Du~chess County
Commission ExpIres t ~J2(p..'Zf)~(J
L BJ-GC-2 (Rev. 4/03)
Page 2 of2
11111111111111111111111111111 --1
..
~r
, GC-2A
-,
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
1< N i c, If r s
Name of Organization
GC- rn - [1Iili] - [ili]JJ - ~
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
(~R"....t K ,.,.~L-l-I Jo~",", L,^ -e+"'''R. I..L.I ~~I f.:L I q c I~ "L". 1"H ~tn.IlJ.)/f k {L\ I J 2-S-<t.~
Dr ~~d /{..... ,~,I 0'\ U e B R O~iV I...!:LI ~I k.L I J.. s- -1,...-.,'1> Pro't' I ~...~ l ~Slr' 11 z.." 6.)
c.~"j/\I<-....(oR 1~1C.1<. 1/4"'" tJ()st-ro.....I~/2::..LI ss-Is-Io ~/OIV'7 f(J.. lf2v~~b'1.sI-e.112{'O?
R~C-a((J~R I O(,C.\< fllvl~'e 1~/~/371S-<t.S.tt\n\~f(A,'d ~t0tie""l.SqO
Tr.q~SL.{Rf'f( 1 ('f\~,! \)~O 1..J..:b.1 ~I b"3.1 2... DV=>'fl"R LN I~I { 2!l-l'o
il-~ II" c "'-+~':I \ ,kA. l{ t I l--.l 1 .J.:1-. 1 32..1 q { I'/' II, ~ 1Ft If f? I f ~X I 12 (...(J 3-
-f rv ~ ~ I I-.l.. 1 ~ 1 E.L I S" 'I-l-~tn-. I. N D IL I ~ k. 1 I L6-'tn-
+(LA8-/-<- I II L/ 9.L../ c, I:> I' ~ ~, /VI",.., ~<>( IlP'/f' ~ I I L,~o
+('\As1-c>e I I~/J..o !(P6 lite. ~<;'e..jU... . )"I~~~ I JLS<ro
I 1_1_1_' . I I
I 1_1___1_' I I
Attach additional sheet if necessary.
[ili] 1 ~ / 1(:)/ GI
Date
SCHEDULE 2: lVIEMBERS IN CHARGE OF GAMES
(MUST LIST AT LEAST FOUR MEMBERS OF APPLICANT ORGANIZATION)
DATE YEARS OF
NAME . OF BIRTH MEMBERSHIP STREET ADDRESS CITY
Ja.~~~ O'Ci4-IlA~ 1--11.. 1 ....2L I..:LLI t)....1.{J 1._1 - J+13 \ c,,+ IIP~ FdY.-
..\ok~ G6e(Y-.~vJl~1 ~o 1 5-21 (q I k~ ~V~4 OK.. Iw'1)9 ~ I
~k,.., s;. ~.'->-' I-L.d ~ / ~ I ? I I S-I i) ~ { IS ~ '0 g (, I J I UJ'yj (~.t2L I
_ t.l.l' 1:t b 1-1l::= 1 -34- 1 b -:3.1 s I :2 Dw-')f '" ~ L- 4 ^"' t# I W &.f' f=q ~ I
, ' I 1 1 I I I I
'-1-1-' II 1
'=1=1=' I I I
I 1 1 I I I I
'=1=1=' I I I
ZIP
i z S-~:n
1 "2..-~-~O
I "'L~~ 0
1"").')96
SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF 2 AUXlLIARIES/AFFlLIATES. EACH AUXlLlARY/AFFILIATE LISTED MUST HAVE ITS OWN ID NUMBER.)
NAME OF AUXILIARYI AFFILIATE
GAMES OF CHANCE ID NUMBER
L BJ-GC-2A (Rev. 4/03)
Page 1 of2
11111111111111111111I111111I1 ~
r _.
I SCHEDULE 4: ASSISTANTS TO MEMBERS IN CHARGE OF GAMES ,.
List all members of applicant organization and members of authorized affiliates and auxiliary who will assist with games. Each person listed must be a
member of applicant organization or affiliate for at least 1 year.
YEARS OF
MEMBER NAME . DATE OF BIRTH MEMBERSHIP STREET ADDRESS
I / / I_I
1-/-/-1_1
1-/-/-1_1
,-/-/-1_'
1-/-/- I - I
1-/-/- [_I
1-/-/-1_1
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1=/=/= I_I.
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,-/-/- I _ I
1=/=/= I - I
1_/_/_1_1
1 / / I_I
1-/-/-1_1
1-/-/-1_1
\-/-/-1_1
,-/-/-1_1
1=/=/= I - I
1_/_/_1_1
I / / I_I
1-/-/-1_1
1=/=/= I - I
I / / I_!-
1-/-/-'_1
1-/-/-1_1
1=/=/= I - I
I / / "_1
1=1=1= In_I
I / / I_I
- /- /- I' I
1__- -
I / / I_I
,-/-/-1_1
,=/=/= I _ I
L BJ-GC-2A (Rev. 4/03)
CITY ZlP
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11111111111I11111111I11111111 ..J
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Attach additional sheet if necessary.
Page 2 of 2