The 4065 Club, Inc
TOWN OF WAPPINGER
TOWN CLERK
GLORIA J. MORSE
SUPERVISOR
JOSEPH RUGGIERO
TOWN CLERK'S OFFICE
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS, NY 12590-0324
(845) 297-5771
FAX: (845) 298-1478
TOWN COUNCIL
VINCENT BETTINA
MAUREEN McCARTHY
JOSEPH P. PAOLONI
ROBERT L. VALDATI
December 14, 2004
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 The 4065 Club, Inc.,
339 Route 82, Wappingers Falls, who will be selling BELL JAR tickets on their
premises throughout the year 2005.
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,
B~C~\\JE.O
f\C f' 111~~~
VI-V
,OWN CLE.f\\Z
TOWN OF WAPPINGER
TOWN CLERK
GLORIA J. MORSE
SUPERVISOR
JOSEPH RUGGIERO
TOWN CLERK'S OFFICE
20 MIDDlEBUSH ROAD
WAPPINGERS FAllS, NY 12590-0324
(845) 297-5771
FAX: (845) 298-1478
TOWN COUNCIL
VINCENT BETTINA
MAUREEN McCARTHY
JOSEPH P. PAOlONI
ROBERT L. VAlDATI
December 14,2004
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 The 4065 Club, Inc.,
339 Route 82, Wappingers Falls, who will be selling BELL JAR tickets on their
premises throughout the year 2005.
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,
3867
THE 4065 CLUB, INC.
P.O. BOX 514, ROUTE 82
HOPEWELL JUNCTION,NY12533
DATE
fa-frlor(
~
$ IS"' (t.-
~~LARS to
1.1288.260
z
~.~'-"; j. ~':}::fA? TO Town Clerk - Town of Wappinger
~ ~(.:1nIE ORDER OF. '
l P~~~--L~
< WACHOVIA BANK, N.A.
WACHOVIA,COM
fOR pd. \ ~~~)
U'OOOO 3Bb?U'
\"'(~0 ~. ZB a ~.: ~ 0 3 0 ~PJ~!tj/r~'-.-:: c ~~- -'"
I
GC-4
NYS RACING & WAGERING BOARD
1 Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (5] 8) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
I
FINDINGS AND
DETERMINATION
FOR GAMES OF CHANCE
LICENSE
GC-rn-~-GJillJ-~
N.Y.S. Identification Number
Town of Wappinger
Name of Municipality
Dutchess
339 Route 82, Wappingers Falls, New 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 application to conduct games of chance are of good moral ~ 0 No
character and have never been convicted of a crime.
Signature of Person Conducting Investigation'
Title .f'.fI'~
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 Ru1es 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)
AI/A
#/.4
ci Yes DNa
ci Yes DNo
0' Yes DNo
rn Yes DNa
ci Y es DNo
dYes DNa
~Yes DNa
DYes DNa
DYes DNo
TOBECOMPLETEDBY~C~ALCLERK: ~
As a result of the findings and determinations stated above, license is GRANTED tit license is DE
Signature of
Filing date of Application 12/14/2004 Authorized Officer
Date
12/29/2004
Town Clerk
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 (Rev. 4/03) 1111111111I 1111111111111I1111 -1
LICENSE TO CONDUCT
GAMES OF CHANCE
PLEASE CHECK
GAMES OF CHANCE 0
BELL JAR 5-
RAFFLE 0
GC - [iliJ- WiliJ- GIill- ~
N.Y.S. Identification Number
I
GC-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
--,
This License Must Be
Conspicuously Displayed
During Conduct of Games
$1: 25.00 J I N/A 1
'Amount of Fee Paid Lessor's License Number
Zip Code: 12533
Address: 339 Route 82 City: Hopewell Junction
Entire net proceeds to be devoted to the following specific lawful purpose(s):
Charity, Patriotic, Youth, Educational
Names of Members in Charge
Peter J. Cassidy
Floyd Scholz
Walter Wych
William Hunt
UCENSE PERIOD
DATE
YEAR 2005
DAY OF WEEK
Sunday thru Saturday
HOURS
TYPE(S) OF GAMES
BELL JAR
AMOUNT OF RAFFLE PRIZES (Cas~ Of Merchandise Prizes
at FlIlf Market Value)
RAFFLE DRAWING
DATE
DRAWING TIME
DRAWING LOCATION
THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
FOR EACH TYPE OF GAME OF CHANCE
$
NUMBER OF GJ;.MES 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.
Issued by
TOWN OF WAPPINGER
(Name of Municipality)
December 29, 2004
(Date)
L BJ-GC-5 (Rev. 4/03)
THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
FOR EACH MERCHANDISE WHEEL
$
NUMBER OF WHEELS
EACH WHEEL
GAMES SHAlL BE PLAYED IN ACCORDANCE WITH
STATE LAWS AND RULES AND LOCAL ORDINANCES OR
LAWS.
I
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
DETERMINATION
FOR GAMES OF CHANCE
LICENSE
o
Municipal License Number
GC - rn - [ilili] - GJill- CQI1ILGL]
N.Y.S. Identification Number
Town of Wappinger
Name of Municipality
Dutchess
339 Route 82, Wappingers Falls, New 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 application to conduct games of chance are of good moral
character and have never been convicted of a.crime.
Signature of Person Conducting Investigation'
Title ..f'~
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.
S. 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)
~/'DNO
/'II II
1'1/ It
liYes DNo
ci Yes DNo
llf Yes DNa
Ell Yes DNo
ct Yes DNo
dYes DNo
~Yes DNa
DYes DNa
DYes DNo
TO BE COMPLETED BY MUNICIPAL CLERK: /
As a result of the findings and determinations stated above, license is GRANTED [i(; license is DENI
Signature of
Filing date of Application 12/14/2004 Authorized Officer
Date
12/29/2004
Title
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 FIRST AUTHORIZED LICENSE PERIOD.
L BJ-GC-4 (Rev. 4/03)
11111111111111111111111111111 --1
I
GC-2B APPLICATION FOR GAMES OF
NYS RACING & WAGERING BOARD eIIANCE LICENSE
1 Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
I
Name of Organization
GC- [Z0 - ~ - ~ - 0ZEE0
NYS Identification Number
[ili]/[2]jJ/[ili]
Date
SCHEDULE 5 DATES, HOURS AND RENT OF ALL LICENSE PERIODS TO BE HELD
(NOT APPLICABLE FOR BELL JAR. GAMES)
DATE HOURS RENT
, J , , J , I am /pm - ,am/pm! $.
, , , . . . , ,. . I.'
, J . ,J . I am /pm - ,am/pm!$ .
, . . . . , . . . la,
, J , . J . I am / pm - ,am/pm!$ ,
. . . . . , . . . ' -
, J . ,J . I ,am / pm - ,am/pm! $.
, . , . . ,- . 1-'
, J . ,J . I am/pm - .am/pm 1$.
, , , I . . . . . . . .
,
, J , ,J , I am / pm - am / pm $,
0 , . . I , I . I , ,. ,
oJ . , J . I am / pm - .am/pm $,
0 . . . , . . . .-
oJ 0 oJ . I ,am / pm - .am / pm $.
. . . . . . . . ,-,
./, oJ . I am/pm - am / pm $.
, . . . . , .. . . I.'
./. . J . I am / pm - am / pm $.
0 . .. . , ' . . 0 ,.,
. J 0 ,J 0 I am / pm - ,am/pm, $ 0
, 0 . . . , . . . . . .
oJ . oJ . I am / pm - ,am/pm!$ .
. . . , . . . 1-'
RAFFLES PRIZES (Cash or Fair Market
DATE TIME
I Value of Merchandise)
oj .J am / pm - am / pm !$. 0 . . 0 '-0 0
. I . .. . . . . . 0
oJ . . J . I am / pm - am / pm !$.
01 . . . . 0 I. . 0 . . .
.J oj I am / pm - am / pm i$.
01 . I. . . ,- . , . . .
, J . oj I am / pm - am / pm !$.
01 . ,- . . I. . . . . .
.J oJ . I am/pm - am / pm !$.
01 . ,8 . , . . . , . . .
SCHEDULE 6 EXPENSES
List items of expense to be incurred, and the names and addresses of persons to be paid.
ITEM OF EXPENSE VENDOR NAME STREET ADDRESS CITY
STATE ZIP
L BJ-GC-2B (Rev. 4/03)
Page 1 of2
11111111111111111111111111111 -.J
I
> GC-2A APPLICATION FOR GAMES OF CHANCE LICENSE
NYS RACING & WAGERING BOARD
1 Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
I
J/;, L.(76J~.
Name of Organization
GC-II 131- 0lEl-I~ 101/ 1-101711 If 1,21
NYS Identification Number
SCHEDULE 1= OFFICERS AND DIRECTORS
List names, addresses and dates of birth of all officers.
If organization is a corporation, or an incorporated or unincorporated association, list officers and directors.
TITLE NAME DATE OF BIRTH STREET ADDRESS CITY ZIP
I 1_1_1_1 I I
I f.e/~,. J CO.sS,'dL I...!L-I --L.I b~ II/) t1o;.~9 I J6~....~ Jtl I /..2.Jf.5
1 r7~ tf 3,d~ 11/..L/ .2;2 l..ul._A'.'11 17, 1 ~","M..,..s" 1 O~bJ
1 au / --1!. /45e7?t no 1-2:..... 1 ~ 1 .5 "'i 13.:s 6 (] 14ft Y tf-I)' 1 -:F7 S 1<'1<, t I I /2-)"Z--~
I /1tJJ,~e/ fJ~r r V 12-/ r:26 1 ,)..5 I 165- 5~ ,b('t'h~q,!.,I1 "cO' fOAgel',<J4:'1 /~5-'yo
"j w/))/-o _ #IA~ I- I Lf!-I .;2() 1 ~ I /() ~ Jc:,~Jr.J1:>'t J t- I FJ-.J'h/~'J/ I /.,25-;./ Y
1 JrJ ~ '7 J Y'~ n.5 I-L-I ,;2 {) 1 ~..3 I ..2 J p~-p,t~/I, jJ,. I }/.;,rt'h/p// JGI I /-'5-fJ
I U/~/;.,.,... Cvy c t. 1-2-1 -1-1 ~ I J j.J dl.,l5Y/~.hhefi..,.,1 )J..pt'u,..// ,]",/ I /~57J
1 . 1_1_1_1 I I
I 1_1_1_1 I I
I 1_1_1_1 I I
Attach additional sheet if necessary.
[]JI 0tJI [ill]
Date
f1?,S,'rl,.., -I
1r-ec,$Li te r-
5ecrelc., y
/
jJ"r-e c.1 c ,..
tf',~redor
[J,'r-e.dtJf' .
t).' r-l1,,-!or-
SCHEDULE 2: MEMBERS IN CHARGE OF GAlVIES
(MUST LIST AT LEAST FOUR MEMBERS OF APPUCANT ORGANIZATION)
DATE YEARS OF
NAME . OF BIRTH :MEMBERSHIP STREET ADDRESS
fe-hr j C~.$'S,'dv 1-2-1 1-1 6>' I ;;/ I. y/ ~r&/'o"d //.
f/o~eI Scl.()/ z./ I ~ 1 6 1 S-,2 I ,;2 7 I;; S- C It>v,.r #,'// ~r
/4-Ctife r- J.4~I.JC L. I 5' /--1- 1 ~- y I /7' 1 /5'3 tMI.5>A~C/n jC/J{e ~;/
wt)J,'-o", )/U,.r I/v 1,;20 1,/;2-1 ..JY l/ofJCtc/(J'I'''''>,t
1=1=1=1 I
1_1_1_1 1
1_1_1_1 I
1_1_1_1 1
1_1_1_1 I
CITY
4/;~/oI'I/ j nl
.
.tt v~, If-,,$,~
... "
j)?jP~/.Pt'// ,}O'
F'--.I J. 1,//1
ZIP
I ./,/ $fJ
I /;2~~ f
I /d~>j
I /..)~.:2 7-
I
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I
I
SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF2 AUXn..IARlES/AFFILIATES. EACH AUXll..IARY/AFFlLIATE LISTED MUST HAVE ITS OWN ID NUMBER.)
NAME OF AUXll..IARY/ AFFillA TE
GAMES OF CHANCE ill NUMBER
11111111111111111111111111111 -.J
L BJ-GC-2A (Rev. 4/03)
Page 1 of 2
if
}~C
I
GC-2
-,
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 CHANCE 0
BELL JAR if
RAFFLE 0
FOR OFFICE
USE ONLY
$1 ~5, te- I
Fees Received
[ill] / [Z[i] / [ill]
Date
INSTRUCTIONS: PLEASE FILE THREE SIGNED COPIES WITH MUNICIPALITY
GC - [LIT] - [2J2li]- [fJill- ~
N.Y.S. Identification Number
IT IS A MISDEMEANOR TO MAKE ANY FALSE STATEMENTS IN THIS APPLICATION
J(J) w n " .{ U/o/:?'p It#<( COP;-- /,vlc 4~ >5
Name of Municipality'/ County
2. Address
3. Has applicant ever been denied a games of chance license? D Yes J;iifNo If "yes", why? (Attach extra sheet if necessary)
4. Check type of organization and, if applicable, give the State and date of incorporation.
Corporation ~
State incorporated 4/ Y 5
Incorporated Association 0
Datern / rn / 151 ~I
Datern/rn/rn
Unincorporated Association 0
State incorporated
Individual
o
5. Did your corporate status change since your identification number was assigned? DYes I2tNo
6. Are you doing business under a trade name? D Yes ~No If "yes", what is the trade name?
PART B. LOCATION OF GAMES
7. Address where games, bell jar, or raffle drawing(s) are to be conducted. .1? 9' ~ocJ/~ ff;2
t.(.IQ~/1-I? '7e r fb//r
/ /
8. Name and address of authorized games of
chance lessor renting to applicant.
'///.17'
9. Does the applicant own the premises? I;;if Yes D No If "yes", how long?
10. Capacity for public assembly of premises presently owned or occupied.
;1 >0
11. Have premises been regularly used? ~Yes D No If "yes", how long?
Are games of chance being played now on these premises or has it ever been? 0 Yes 0 No If "yes", give full details.
12. Are the premises or any part thereof
where games of chance are to be played
licensed by the State Liquor Authority?
ElYes D No
If "yes", state the type of license and number.
()" I't~""St5t.$ /''pI'''I' /l'celf"e
~()O J - ,). tlwl-c t!} P S"/O;2J;1.
13. Has such license ever been 0
revoked or suspended? Yes
~No
If "yes", why? (Explain on a separate sheet, if necessary, and attach.)
L BJ-GC-2 (Rev. 4/03)
Page 1 of2
11111111111111111111111 111111 ..J
I
GC-4
NYS RACING & WAGERING BOARD
1 Watervliet Ave Ext., Suite 2
Albany, J\TY 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
o
Municipal License Number
GC-m-~-[iliL]-~
N.Y.S.ldentification Number
Town of Wappinger
Name of Municipality
Dutchess
339 Route 82, Wappingers Falls, New 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 application to conduct games of chance are of good moral .~ 0 No
character and have never been convicted of a.crime.
Signature of Person Conducting Investigation'
Title /j1'~
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.
S. 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 orrecompense 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)
ci Yes DNo
ci Yes DNo
IZf Yes DNo
[!j Yes DNo
dYes DNo
dYes DNa
B' Yes DNo
1'11.4. 0 Yes 0 No
IV/A- DYes DNo
TO BE COMPLETED BY MUNICIPAL CLERK: /
As a result ofthe findings and determinations stated above, license is GRANTED [i( license is DE
Signature of
Filing date of Application 12/14/2004 Authorized Officer
Date
12/29/2004
Town Clerk
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-GC-4 ~ev. 4/03) 1111111111I1111111111111I1111 .-J
I
GC-2A
APPLICATION FOR GAl\1ES 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
GC-I/ 131- 0M -I&; 101/ 1-10171; If 1;<.1
NYS Identification Number
[]]/0t]/[ill]
Date
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
I 1_1_1_1 I I
I ~/~,. J Co.J5,'cI L. I ~ I -L- I b ~ I fl ~ po/'-;t 9 I J6pWe?....?" Jtl I /-25:5 5
I 7,'i""'- .4 5c dlz I-L / -L- / 5,2 1,.1 >C/o- AI) 1/ 17, I ~ ""1,&'..,...,, I /.2': t]
I Ut, / --tAr UePtno I '2- I 70 I 5~ 13~6 eM-Y Itl)' I -nSf<l<d I I /2-)Z--::.j
I ,/1,-J:f,ke/f''f!rrv 1--2'-102{:;' I ~3 l/ti5-5 ,b"rJI'~,/h6J"l.tc6"r"".H7ei/)J*,1 /.25-YC
In-t: dOlr:1 U"/'j)t-o 'rt JltA~1 J- I / c; I ;Lv I ~,z.. I /07 JCt/).$t-...z ; r I /"t.fJj{,'J/ I ),,2 5-;;> y
fJ,'r-e: d or-' I .-Jd ~ ~ J yC' n.> I..L- I ;2 t,' I '7..3 I .2;; ft~ 'a;,/.d~ .PI" I #,/,01:''>// JL/ I /.;) 5-SJ
(l"r-t>,,-!v,- IU/CJ/-kr- :Vyc;' 1..L1-1-1 j7'.I/f.Jc?l.....5y/u;...h~,,:.....I#r"LN'//Jf/ I /.-L57.J
I . I_I _I _I I . I
I 1_/_/_1 I I
I 1_/_/_1 I I
Attach additional sheet if necessary.
OFFICERS AND DIRECTORS
ft?5''dl'''f f
1,['>"$/,1 re r-
5ect'~/Ct. y
/
!Jf're Co I- c r-
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
rein j C&,~,'dv 1...2-1 2-1 6S- I ;2/ I J/ L'r.:tOtd //
f/c"e! 5c/'c/z./ I~I ~I $"",2 I ;27 1 -'5"' C/CL'I>r /'1.'// t:Jr
u,,,I;e r- J/-'YC-" 1----2- I -L- I ~-)/ I /};7 1 /53 tJJ~ S>-lcm Jd{f'
?vtJ),'Om II iud- 1 ~ I .;2() I '/;2- I ;) y 1 /tif ..Tv');';""'" 5,1-
1_1_1_1 I
1_/_/_1 I
1_/_/_1 I
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1_/_/_1 I
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CITY
.u.~tp>// jot
.
~vc'If-,..5/~
,. ,
#/PUJp// ,JtJ
;:,':1 ),/",/J
ZIP
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I
SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF 2 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 of 2
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I
GC-2
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NYS RACING & WAGERING BOARD
] Watervliet Ave. Ext., Suite 2
Albany, NY 12206-]668
Te]ephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
APPLICA TION FOR:
PLEASE CHECK
GAMES OF CHANCED
BELL JAR i1'
RAFFLE 0
FOR OFFICE
USE ONLY
Municipal License Number
$1 ,<5, e I
Fees Received
0Il / [ill] / [ill]
Date
INSTRUCTIONS: PLEASE FILE THREE SIGNED COPIES WITH MUNICIPALITY
GC - [LEJ - [2]2E- ~ - [ili]2Jill
N.Y.S. Identification Number
IT IS A MISDEMEANOR TO MAKE ANY FALSE STATEMENTS IN THIS APPLICATION
){p w ,., p I WDJ:!J:?;"#1 e;p r- /,v/~ 41.""'>5
Name of Municipality ./ County
2. Address
3. Has applicant ever been denied a games of chance license? 0 Yes J;;;fNo If "yes", why? (Attach extra sheet if necessary)
4. Check type of organization and, if applicable, give the State and date of incorporation.
Corporation II
State incorporated A/ Y 5
Incorporated Association 0
Date OJ / OJ/15\ ~I
DateOJ/OJ/OJ
Unincorporated Association 0
State incorporated
5. Did your corporate status change since your identification number was assigned? 0 Yes !2tNo
Individual
o
6. Are you doing business under a trade name? 0 Yes ~No If "yes", what is the trade name?
PART B. LOCATION OF GAMES
7. Address where games, bell jar, orraffle drawing(s) are to be conducted. 1? 9' ~o"/~ fj-,;2
tVo ~p ffl ~ e,.. Ii, /1 f'
/ /
8. Name and address of authorized games of
chance lessor renting to applicant.
/l/;f
9. Does the applicant own the premises? i;il'Yes 0 No If "yes", how long?
1 O. Capacity for public assembly of premises presently owned or occupied.
;1 ~o
11. Have premises been regularly used? ~Yes 0 No If "yes", how long?
Are games of chance being played now on these premises or has it ever been? 0 Yes 0 No If "yes", give full details.
12. Are the premises or any part thereof
where games of chance are to be played
licensed by the State Liquor Authority?
elYes 0 No
If "yes", state the type of license and number.
on ;nIi>Wf>s"6$ /''pJ-Dr li"'ceH~e
;J.OOJ -;). t/vl-c.. & P S-/O;2S-;z.
13. Has such license ever been 0
revoked or suspended? Yes
~No
If "yes". why? (Explain on a separate sheet, if necessary, and attach.)
L BJ-GC-2 (Rev. 4/03)
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11\11111I111111\ 11I1111111111 .J
I 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 for Ve2as Ni2hts 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)
LIST THE MAXIMUM AMOUNT OF PRIZES
TO BE AWARDED FOR EACH TYPE OF
GAME OF CHANCE (GAME BANK)
at $
at $
at $
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 APPLICATION
IS FOR A BELL JAR
LICENSE
YES~NO 0
THE TOTAL AMOUNT OF PAYOUTS
FOR EACH BELL JAR DEAL SHALL NOT
EXCEED $3,000 AND NO SINGLE PRIZE
SHALL EXCEED $500
RAFFLES:
INDICATE IF THIS APPLICATION
IS FOR A RAFFLE
LICENSE
YESD NO 0
IF YES, LIST RAFFLE DATES, TIME(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-2B (Rev. 4/03)
Page 2 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.
C/'Orr iv. /a/-rJ'() -ire. 110' .,.;;14. Ee:;r/vc-c,I,to~a/
// / / /
.-,
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.
[ill] / [iliJ / ~ IJ- / ~
Date Signatureuf Head of Organization
STATE OF NEW YORK
,{/-Pr Y Lc.-S5IVy
Print Name '
I
}ss
COUNTY
OF
DurC!..I-I€S S
~OWNrV.l:l...:Un.~
OF &)fJ.ffl IV r;e ~
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
day of
,20
Signed
Commissioner of Deeds
Notary Public
My Commission expires
,20
L BJ.GC-2 (Rev. 4/03)
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1111111I111111I111I11111111I1 .J
r I
GC-2B APPLICATION FOR GAMES OF
NYS RACING & WAGERING BOARD eIV,J-4CE LICENSE
1 Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
~ameOfOrganization -. . . . . . .
GC- [Z0 - 02JlJ - 0illJ - ~ [ili] I [ill I [iliJ
NYS Identification Number 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 am /pm - ,am/pm! $ ,
.... . , . i . . , t . . . . 1
, f , ,I . I ,am / pm - ,am/pm! $.
"'-- . , . . . . I . . i. .
> f . ,I . I am/pm - ,am/pm! $ ,
, . I . . , I . . . . .
./. . I . I am / pm - ,am/pm! $ ,
, . . , ,- . I. .
./. , f , 1 am / pm - ,am/pm! $.
, , . . . , . . . I. .
./. ' I . I am / pm - ,am/pm! $.
, , . . . , I . . ,., ,
> f . ,f . I am / pm - ,am/pm! $.
"- . I . . , . . . 1-'
./. ' I . I am / pm - .am/pm!$.
. . . . . , . . . I.'
./. , I , I am / pm - .am/pm ! $.
, . , . I . . , I. . ,. .
, f . ,I . I am / pm - ,am/pm! $.
. . , . . . . , . . . "
./. , f . I am / pm - ,am/pm! $.
, . I. . , I. . I. .
./. ' I , I am / pm - ,am/pm l$.
~ . . I. . . i . . ,- I
RAFFLES PRIZES (Cash or Fair Market
DATE TIME
.f .1 I Value of Merchandise)
am / pm - am / pm !$. , , . . ,'. .
. I . .- . . . . . ,
~ f I .1 I am / pm - am / pm !$.
. I . .- . . .- . . . . .
~ f . ,I I am / pm - am / pm !$
. I . . . , . ,- . , ' . .
./. .f I am / pm - am / pm !$.
. .1 . . . . , I. . . . . .
.f .1 I am / pm - am / pm \$
. I . ,a I . .- . i . . .
SCHEDULE 6 EXPENSES
List items of expense to be incurred, and the names and addresses of persons to be paid.
ITEM OF EXPENSE VENDOR NAME STREET ADDRESS CITY
STATE ZIP
L BJ-GC-2B (Rev. 4/03)
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GC-2A
I
APPLICATION FOR GAMES OF CHANCE LICENSE
NYS RACING & WAGERING BOARD
1 Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
/ t I F '4 (\ t~ r
~ .."/ I~ / - .
Name of Organization
GC-I/ 131- rwm -I~ lall 1-/0171/ If 1;<.1
NYS Identification Number
SCHEDULE 1: OFFICERS AND DIRECTORS
List names, addresses and dates of birth of all officers.
If organization is a corporation. or an incorporated or unincorporated association. list officers and directors.
TITLE NAME DATE OF BIRTH STREET ADDRESS CITY
I 1_1_1_1 I I
I f'.el~,. J CO.$s,'elL. 1.2:-1 1-1 b~ I fJ~ ;50".;29 I J6~...?" J~I I /..2~.5]>
I %,0/./ /I 3,.([~ I.J) ~/ 53 I.>UI._,jI,'/1 p, 1~","Mry-s" I 003"
I U'i /~. /45efrtno I...:!::.-I 7.u I lEi. 13~6 (!~V tf-t)' I HS/'fl<tf I I n.....)'Z..-.:/
I /1,'/:f,be/ f'-erl~V 1--2-1 ,;2{;, I ,)3 1/65-5 'Oc,r),'pD"h.,lI.tGbi'...,....~e',}J/f>1 /.25-7'0
I U"f/JroH1 )/U~1J- 1Lf!....1 .)..tJ I ~I /07 JC,'/).>P'l Jr I /"u},Jr:J/ I /,,25:,) Y
I :Tt,1 ~ '7 /y{1 n f I-LI ;2t/ I '7.3 I .27 p~~/.d~ ,tJj- I #,reuJ'>//JG/ I /..'5'>J
1 U/c.r/Ie r ~y C t, 12-/ ..1-1 ~ I J 7] dl.......$'y/U..hAeA'...-' I #Jf'Ptn<// ,]"(1 I /.2.57J
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Attach additional sheet if necessary.
fT?5.'dI"'f .;
ir-pc,$/,t re r-
5ect"@Ic.l Y
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JJt't. e c. fer-
tlr H:. L- -I" i/-
fh",u-/f)(' .
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Date
ZIP
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
~~,. j Ce,.$SI'dV 1-2-1 1-1 &~ I ;J/ 1. J/ ~rC/'O~d //
flo~tI Scl,()/z./ I-L I ..L.- I S-,2 I ;; 7 I;; S- C IOi....r rI.'// t:Jr I
/A'IA/le r- },j/vc." 1---2- I -1..- I ~-)/ I /;7 1 /53 oj,! Sy;/r-n '",Jre ,lie! I
wt/),-o", ;;.....1' I /() 1,;20 I '/:2-1 -,y l/of.JG-l)(;...."IS,t I
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CITY
,1,6#11'101"'// j ~;I
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~ vc' 1f-P'h{D
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JP/i>U7P// .JOL
Fi:1 J, /,// J
ZIP
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SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF 2 AUXILIARIES/ AFFlllA TES. EACH AUXILlAR Y/ AFFILIATE LISTED MUST HAVE ITS OWN lD NUMBER.)
GAMES OF CHANCE ill NUMBER
NAME OF AUXILIARY/ AFFillA TE
III 1111 I 1111l11I1I1ll1I1 III " .-J
L BJ-GC-2A (Rev. 4/03)
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