Knights of Columbus #1646
I
,GC-2
I
APPLICATION FOR:
PLEASE CHECK
GAMES OF CHANCED
BELL JAR )d
RAFFLE 0
$\ ;.5, bE
Fees Received
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
FOR OFFICE
USE ONLY
[l]] / IIIQJ / 0t]
Date
INSTRUCTIONS: PLEASE FILE THREE SIGNED COPffiS WITH MUNICIPALITY
GC - ITliJ - 12ILI5J- lliIQ]JJ - 10 I All 12 101
N.Y.S. Identification Number
IT IS A MISDEMEANOR TO MAKE ANY FALSE STATEMENTS IN THIS APPLICATION
_lOLVIU 0(: WAPP IrJhPJ< DU:rCHe55
Name of Municipality County
2. Address
COL.u.MBUS
ll.4 A-i ~ Sl110o\; LDAtPPllAJ (...Q.Af4<) Fv-\-U.Sj Wi LZ~70
3. Has applicant ever been denied a games of chance license? 0 Yes ~o 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'lv(
)i"\ State incorporated
Individual 0
Date 0] / OJ / OJ
Date 0] / OJ / OJ
5. Did your corporate status change since your identification number was assigned? 0 Yes ~'NO
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, or raffle drawing(s) are to be conducted. 1 t:.AS\ "-'1 Ai ~ S\12aI-r) Li.J FNY
8. Name and address of authorized games of
chance lessor renting to applicant.
9. Does the applicant own the premises? '~Yes 0 No If "yes", how long?
10. Capacity for public assembly of premises presently owned or occupied.
11. Have premises been regularly used? JirY es 0 No If "yes", how long?
Are games of chance being played now on these premises or has it ever been? ~Yes
B~U ~ 'J PrYt \
'37 U P A-\'2..S
\
3\9
3 7 '-(eAYLS
o No If "yes", give full details.
12. Are the premises or any part thereof
where games of chance are to be played PJ: Yes 0 No
licensed by the State Liquor Authority?
If "yes", state the type of license and number.
CLl..tb \ Y CL ,-)4
13. Has such license ever been 0
revoked or suspended? Yes
~NO
If "yes", why? (Explain on a separate sheet, if necessary, and attach.)
B.1-GC-2 (Rev. 4/03)
Page 1 of2
11111111I111111\ 11I11111'1111 .J
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PART C. PURPOSES OF GAMES
]4. State the specific purposes for which the entire net proceeds are to be devoted and in what manner.
C l:tiH2/ i 'T A-v?JLP_ Do ~ A-ll 0 ~S) M A- \ vJ\ ev-J.400 C1? 0 F B~ \\ 0 \ NG-
I swear (or affirm):
1. That AU. the attached Schedules are a material part hereof and are incorporated herein as if set out in full in the application. All the an$wers
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 pe 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 resporisible for the holding, operation and conduct of all games of chance in accordance with the terms of tj1e 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 Re~ulations
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 B~ard.
rn/rn/~ ~ v-A- ~~
Date Signature of Head of Organization
"1~~
Print Name
NV~~
}SS
CITYfTOWNNILLAGE OF '-lJA-??~tVt~C(,. ~ ~L~~ j'
-M~flIIII'PS tv) , L A:}c..H ur . being duly sworn deposes and says that(s)he is the person above na ed,
that (s)he has read the fOreg~ing statement and the answer therein noted, and that such answers are true and that (s)he has perso. ally
affixed his (her) signature to this affidavit.
STATE
OF
NEW YORK
COUNTY
OF
D~c..l~~~~
o~~- S-~- VL6b
Sworn to before me this 30
day of b>'U:-
,2004
Signed ~~,. .~
-
Commissioner of Deeds
My Commis e re
Raymond Charles Chase, Jr.
Notary Public State of New York
Qualified In Dutchess County
No. 4606965 .
Comm!lIIon Expll'8$ Jan. 30, 20 D b
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l_ BJ-GC-2 (Rev. 4/03)
Page 2 of2
11111111111111 " III II 111111 -1
NYS RACING & WAGERING BOARD
1 Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492 .
""'~'I~I 1~ldLILZIMIBI~
~
GC-lilil- ~ - mIJ -1012.11 \1101 [iJiJ 1 [ili] 1 [0 [lfl
NYS Identification Number Date
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
GI1.A\.lD JL"'~i=~~Ln(lj..c, In) -1,.../ J.!:L I {,'8 SOLLllt M€>1e4 WFoJ:-{ 1_10110
\\>-1> G12f\uo K.I ~_j't\'.JO 13-1 .:LI 2.-1.iJ:tAM LI'^J Rb I I Ut=W-j I i ",:01 0
W~oJ l;fen'" Su~IQR 121 15' 1~1112 0,\1-e<~ ~JPo","'~I;,[ \'4,01
C~UOO.J~,j C~T"""~ 1 ~ 1 23-1 ~Iq Wli\&m1 T~ WRJ-1-1 i 2:','10
~ !;)v1rAfe .1 , \ 0\-\ w Pn(}.)e{I,>, 12-.1 -?- 1 JfL l?d wl'\l"rd;'r~ ucl (p ~ I I &'.00
J....:sI~.(.;,i>o.cl ~ = I~I i3f:LI ~ 113 ~,!J\JIS u{L I LUHcri I I :z.o,"fQ
Tt7 ,/"-\ <'Q I ThO'\A ,y.:; ..J 1-2-1 ...kz 1 k20..1 i 10 Av.J$NGA QD I I,1.J RJ'j I 12..<:."70
\!WS,f'O- I " \ \ . L2Jill /;{j.J ~ I I:td /I,~ Te.I2(l.1 Po,,~d I U,Q l-
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Attach additional sheet if necessary.
r
. GC-2A
APPLICATION FOR GAMES OF CHANCE LICENSE
I
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
:r4o~ O(~ -1L 1 J...{ 1 5"'/ I 23 \.1 H1~ S+narc I
~oh~ 5:1 ~O~ I II 1 I ~ 1 Scf I 20 I r l Dt2LhA-<;t) f-3Lv01
.::lQh-u ~tWl ~ 1 J..jLI ..D..I 1,,<" I I,) ~J~It;J" 1
"(110mB;.) l-jNt i+1-L- 1 :J.~ 1 1-0 I ~ ~ l:i~ At<5f\_ D p, b I:
1_/_1_1 \ I
1_/_1_1 I \
1_/_1_1 I \
1_/_1_1 I \
1_/_1_1 \ I
CITY ZIP
W PvV'1 I I u'tJo
co FvJ1--1 JL:{Cl()
w ~, I I 2..)'tf 0
w ~N:t==l j7,j10
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SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF2 AUXll..lARIES/AFFlLlATES. EACH AUXlLlARY/AFFILlATELISTED MUST HAVE ITS OWN ID NUMBER.)
NAME OF AUXll..IARY/AFFlllATE
GAMES OF CHANCE ill NUMBER
L BJ.GC-2A (Rev. 4/03)
Page lof2
1111\\1 I 11\1 \1111 11111 1I1I111 --1
r SCHEDULE 4: ASSISTANTS TO MEMBERS IN CHARGE OF GAMES. -,
LiSl all members of applicant organization and members of authorized affiliates and auxiliary who will assist with games. Each person listed ~luSt be a
member of applicant or~anization or affiliate for at least I year. . i"
YEARS OF
MEMBER NAME . DATE OF BIRTH MEMBERSHIP STREET ADDRESS
, / / I_I
1=/=/= I _ 1
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1=/=/= I = I
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1=/=/= I _ I
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Rl-~r-2A (Rev. 4/031
Attach additional sheet if necessary.
Pal!e 2 of 2
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,GC-2B APPLICATION FOR GAMES OF
NYS RACING & WAGERING BOARD CHANCE LICENSE
1 Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
::ril~~a\;lllql- ~-~ [ili)l[illJ/[ol'il
NYS Identification Number Date
SCHEDULE 5 DATES, HOURS AND RENT OF ALL LICENSE PERIODS TO BE HELD
(NOT APPLICABLE FOR BELL JAR, GAMES)
RENT
,am/pm!$ 1 .J . .
,am/pm! $. . .
,am/pm! $. .-L.
,am/pm l$. .-,
,am/pm \ $ , ,.,
,am/pm \$ , '.1
,am/pm!$ , ,.,
,am/pm !$ .Jal
,am/pm! $. .-,
,am/pm \$ , .-,
,am/pm! $. .-,
,am/pm \$. I.'
DATE HOURS
/ / I am / pm -
, . , , . . , , , I . . . . . .
,
/ .'''";1 I am / pm -
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/ / I am / pm -
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/ / I ~/pm -
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am / pm -
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/ / I am/pm "........
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..... . . , . , , , I- . ~ .~ I. .
/ / I am / pm - .
~ I , I , . , . . . I ' , "" - i . .
,
RAFFLES ',-
"'-,
DATE TIME '-'"...
'.,
/ / I am / pm -
. .. , , 1 . I. . , I. .
/ / I am / pm -
, . , , I I . . . , Jl . .
/ / I am / pm -
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/ / I am / pm -
: ~ . , . . 1 . I. l . I. .
/ / I am / pm -
L- I . I . i. . I i . .
PRIZES (Cash or Fair Market
Value of Merchandise)
,aD;1/ pm ! $ . . . , . , . . .
,am/gm ! $. ,.,
,am / pm:..t$ . ,.. .
,am/pm \$. , ,..
,am/pm! $ >.\ . ~'.
,
,
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 S)~TE ZIP
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L BJ-GC-2B (Rev. 4/03)
Page lof2
\\1\1\ \ \\1 \1\\1\\\1 \'\\\1\11\ ~
I SCHEDULE 7 TYPES OF GAMES --,
List all of the single types of games to be conducted at all license periods enumerated in Schedule ~.
Note for Ve2as Ni2hts and Bazaars onlv: The total amount of prizes during anyone license peri~)d shall not
aggregate more than $400 for each single type of game of chance when five types of games of chan~e are to be
conducted during anyone license period. The total amount of prizes during anyone license period Ishall not
aggregate more than $500 for each single type of games of chance when less than five single types bf games of
chance are to be conducted during anyone license period.
LIST NAME OF EACH TYPE OF
GAME OF CHANCE
(Limit: 5 Games)
UST THE MAXIMUM AMOUNT oIt PRIZES
TO BE AWARDED FOR EACH TWE OF
GAME OF CHANCE (GAME BAjN--..K)
. I
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 If OR
I
EACH MERCHANDISE WHEEL SHALL
NOT EXCEED $10,000 AND NO SIN~LE
PRIZE SHALL EXCEED $250
BELL JAR:
INDICATE IF THIS APPLICATION
IS FOR A BELL JAR
LICENSE
YES):( NO 0
THE TOTAL AMOUNT OF PAY~UTS
FOR EACH BELL JAR DEAL SHALLINOT
EXCEED $3,000 AND NO SlNGLE PJjtIZE
SHALL EXCEED $500
RAFFLES:
INDICATE IF THIS APPLICATION
IS FOR A RAFFLE
LICENSE
YESD NO 0
IF YES, UST RAFFLE DATES, TIME(S)
OF DRA WING(S) AND PRIZES IN
SCHEDULE 5
THE TOTAL AMOUNT OF PRIZES JOR
ALL THE RAFFLES CONDUCTED OUR-
ING THIS CALENDAR YEAR S~ALL
NOT EXCEED $100,000. NO S LE
PRIZE SHALL EXCEED $5 ,000
EXCEPT THAT A SINGLE pRIZIj. OF
$100,000 MAY BE AWARDED IF I SO
INDICATED IN SCHEDULE 5
R T.r.r.2Jl (Rev. -1/03)
PU!W 2 of 2
1/11/111111 1111111 11111 111111 ~
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
--,
FINDINGS AND
DETERMINA nON
FOR GAMES OF CHANCE
LICENSE
GC - [ili] - [ili@ - GliGJ - ~
N.Y.S. Identification Number
Town of Wappinger
Name of Municipality
icip 1 Law, the following findings and determinations
~s 0 No
ingers Falls, New York 12590
Address
~)lxf\ff-
After investigation, and a hearing if required under Sec. 192 f the General M
have been made:
1. All the members-in-charge designated in the pli
character and have never been convicted 0 a cr'
Signature of Person Conducting Investigatio
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)
IV/A
J11~
EI Yes DNo
1KI Yes DNo
~Yes DNo
~Yes DNo
18 Yes DNo
.BI Yes DNo
1&1 Yes DNo
C; Yes DNo
DYes 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 12/30/2004 Authorized Officer
1//f-/~5
. ,
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.
1111\\111111111\1\1\ \11 U\\ll -1
Title
Date
L BJ-GC-4 (Rev. 4/03)
. .
-,
r
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
LICENSE TO CONDUCT
GAMES OF CHANCE
PLEASE CHECK
GAMES OF CHANCE 0
BELL JAR "'-
RAFFLE 0
GC - [ill] - GI!IiJ- GIQJ1J - WlLIiliJ
N.Y.S. Identification Number
This License Must Be
Conspicuously Displayed
During Conduct of Games
$1 25 _ 00 II I
Amount of Fee Paid Lessor's License Number
Address: 2 East Main Street City: Wappingers Falls
Entire net proceeds to be devoted to the following specific lawful purpose(s):
Charitable Donations, Maintenance of Building.
Names of Members in Charge
James O'Connor
Zip Code:
12590
John Simons
John Gorman
LICENSE PERIOD
DATE
Year 2005
DAY OF WEEK
HOURS
TYPE(S) OF GAMES
Bell Jar
RAFFLE DRAWING
DATE
DRAWING TIME
DRAWING LOCATION
AMOUNT OF RAFFLE pRIZES (Cas~ or Merchandise Prizes
at FlUr 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
$
EACH WHEEL
NUMBER OF GAMES
EACH GAME (Starting Bank)
NUMBER OF WHEELS
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
TOWN OF WAPPINGER
(Name of Municipality)
January 12, 2005
(Date)
orized Officer)
11111111111111I11111111111111 ~
L BJ.GC-S (Rev. 4/03)
.
TOWN OF WAPPINGER
TOWN CLERK
GLORIA J. MORSE
SUPERVISOR
JOSEPH RUGGIERO
TOWN COUNCIL
VINCENT BETTINA
MAUREEN McCARTHY
JOSEPH P. PAOLONI
ROBERT L. VALDATI
December 30,2004
TOWN CLERK'S OFFICE
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS, NY 12590-0324
(845) 297-5771
FAX: (845) 298-1478
Adrian Anderson, Sheriff
150 North Hamilton Street
Poughkeepsie, NY 12601
Dear Sheriff Anderson:
Enclosed, please find a copy of "members in charge" of the Knights of
Columbus, Wappingers Council #1646,2 East Main Street, 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 please complete
the "Findings and Determination" form attached.
Thank you for your attention to this request and your prompt reply.
Yours truly,
o
smk
Encl.
BELL-JAR-GAMES OF CHANCE
WAPPINGERS COUNCIL K OF C 1646
186
1-106/260
c......
b ...
1~'f
$12.J-~
Ii.
DOLLARS \
O ~E. Ll.. ~ ~ ~ t...:.f:>e.-Jc.-t.
F R
:0- I: 0 28 0 0 . 0 B . I: 0 B 2 7 5 5 ~ 2 2111
~~ tt-'-
Id~ Y'-.Fr29.0-
O.Bb
~
{fi HARLAND tWO
08134
FOR
D CASH
~HECK
D M.D.
BELL-JAR-GAMES OF CHANCE
WAPPINGERS COUNCIL K OF C 1646
186
1-108/280
L-
b "
I ;
DOLLARS '
FOR l1~ \..L- ~ ~:\... l-:,seN(.,t.
> I: 0 2 BOO .0 8 . I: 0 8 2 ? 5 5 ~ 2 2 III
:Ajj,~~,.rL-- ~
~~ Y<..R9%r
0.81;
~
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08134
FOR
D CASH
~HECK
D M.O.
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,GC-2
--,
APPLICATION FOR:
PLEASE CHECK
GAMES OF CHANCE D
BELL JAR )d
RAFFLE D
$1 ).5,OE
Fees Received
NYS RACING & WAGERING BOARD
1 Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 4.53-8460 Fax (518) 453-8492
www.racing.state.ny.us
FOR OFFICE
USE ONLY
[L]] I [I[Q] I loJlf1
Date
INSTRUCTIONS: PLEASE FILE THREE SIGNED COPIES WITH MUNICIPALITY
GC - ITliJ - [&Q5J- ~ - ~
N.Y.S. Identification Number
IT IS A MISDEMEANOR TO MAKE ANY FALSE STATEMENTS IN THIS APPLICATION
_I OCVU Or: WAPP! I\Jr-PJ~ Uu..-rCHe..5S
Name of Municipality County
CO l.LMI3US bY.
Sll'"JOol; LOICrtDPI \AJ (...QA'2.,S n6rU.S/ Wl( I Z''SSO
3. Has applicant ever been denied a games of chance license? 0 Yes ~o If "yes", why? (Attach extra sheet if necessary)
2. Address
4. Check type of organization and, if applicable, give the State and date of incorporation.
Corporation D
Incorporated Association 0 State incorporated
Unincorporated Association'lvl"
)0\ State incorporated
Individual 0
Date 0 I 0 I 0
DateD/DID
5. Did your corporate status change since your identification number was assigned? 0 Yes )?t'NO
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 raffle drawing(s) are to be conducted. 1 SAS'I tv( )q-j t-J 5117cOT u,.) FNY
)
8. Name and address of authorized games of
chance lessor renting to applicant.
9. Does the applicant own the premises? .~ Yes 0 No If "yes", how long?
10. Capacity for public assembly ofprernises presently owned or occupied.
11. Have premises been regularly used? )fYes 0 No If "yes", how long?
Are games of chance being played now on these premises or has it ever been? ~Yes
Bi? U- 'J rarrt ,
37 U p.A-\2..5
\
3\9
3 7 '1 eA'rLS
o No If "yes", give fun details.
12. Are the premises or any part thereof
where games of chance are to be played ~ Yes 0 No
licensed by the State Liquor Authority?
If "yes", state the type of license and number.
CLGlb \ Y CL 54
13. Has such license ever been 0
revoked or suspended? Yes
~NO
If "yes", why? (Explain on a separate sheet. if necessary, and attach.)
BJ-GC-2 (Rev. 4/03)
Page 1 of2
llllll\ll\ 11l11\ 1111111111111 ~
r
PART C. PURPOSES OF GAMES
]4. State the specific purposes for which the entire net proceeds are to be devoted and in what manner. I
C ~\ TA-~LP_ DC') ~ A-1l 0 v..JS, fv1 AI vJ\ ev-JA-uJCf? of
[ ''''''' (onmnD), / Billm NG-
1. That ALL the attached Schedules are a material part hereof and are incorporated herei~ as if set out in full in the application. All the ans1ers
contained in this application are a material part hereof. I .
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 ~ames of
Chance Licensing Law and the Rules and Regulations of the Board. ' , I
-=1
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 b held,
operated and conducted, who is familiar with the Games of Chance Licensing Law, the Rules and Regulations of the N.Y,S. Racing & W ering
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 tbe terms of th 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 p.ovisions
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 Regu ations
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 orl
conducting of the games, except to bookkeepers or accountants for professional services in an amount not exceeding that fixed by the Bo1rd.
I
i
I
GliJ/rn/~ ~ ~ ~ill
Date Signature of Head of Organization
"'f""'.~
Print Name
~-
STATE
OF
NEW YORK }
D~c.~~~~ ss
'-fJ,A.?(~~t~~_l. ~L\S,'"
o~~,... ~~,... UL6b
COUNTY
OF
CITYITOWNNllLAGE
OF
""'^~~"..s /'II, L~~e.-H "ill: . being duly sworn deposes and says that (s)he ~s the person above nam~,
that (s)he has read the foreg ing statement and the answer therein noted, and that such answers are true and that (s)he has personfllY
affixed his (her) signature to this affidavit. I
I,
I .
Sworn to before me this
60
day of 'b>t...c::-
,2004
Signed
Conunissioner of Deeds
My Commis e re
Raymond Charles Chase, Jr.
Notary Public State of New York
QualifIed In Dutchess CQunty
No. 4606965 '
Comm!88fon 'Explr8$ Jan. ,30, 20 D b
1_ 8J.GC-2 (Rev. 4/03)
Page 2 of 2
1111111I111I111111I111111111 -.J
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 .
GC- [ili] - [2Jill] - ~-IOI2.11 12101 rn I [lli] lid [tf!
NYS Identification Number Date
SCHEDULE 1: omCERS 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
G-r1.A\.lD JLrJr;mt~~1/2/ll J;oJ f2 SoLLTl+~ L!,)f~--{ LI"Z.':.'7fO
~(.;-Mu{) \(.1 ' a :1.3_1 .:LI ~lJ ~LI~ Rb I lJ.J\:::W'1 I 12-<'010
wAf2,oo;0 I . L2J 15' I ~ I 11'2- C<> \ 1.eGe, I'>..eI rQU.G.~I;,[ I U,o I
C~11.0QJ:fph rJ (' MTIWR. I S I %1...1 ~ I 9 €L11A8effi T~ lDR.l'1--1 I '2.StlQ
AW'f'A!e. I ~o"'t.\ PnllJ~ 12.-1 ;z-I M I :3::lwh IW-~~ Wf"t.J'.1-U v,'1f 0
T)d>lrP-~t;:~ ~I-"-I i&1..Rlji'l i)>!JiJ\S uQ ll,J+=vJ'1 1/2.~'90
1fl LIS-I f'li I' -.) 1..2...1 .:k211dl.11 Ie A'/JSAflA (.(0 I l,lJ RJ'-( 1..J2~"9Q
IMST'<>O.. ~~ ~1__~Un/~I"i1 f-b.l11,~TeJUtIPo'-l~ i~OL
T 1WST'.ea... ' . . 1.-1...1.Q.1 ~ 1 lbOSf' R:te ?i71a I W R-v'1 I 1'2..$9 0
\ . 1_/_1_1 I I
I '. 1_/_1_1 . I I
Attach additional sheet if necessary.
r
. GC-:2A
APPLICATION FOR GAMES OF CHANCE LICENSE
I
SCHEDULE 2: MEMBERS IN CHARGE OF GAMES
(MUST LIST AT LEAST FOUR MEMBBRS OF APPLICANT ORGANIZATION)
DATE YEARS OF
NAME . OF BIRTH :MEMBERSHIP STREET ADDRESS
::r~..a:: O~ II I ')..s I 5"1 1 ),3 llil:l~. I
~r;rJ $1 \vIO~ I II I lfa I S<I 12-0 1,<; I A<;t'} ~I
~h~ GoQl4~Il-1 J!:LI ~I l~ I l0 l--{.> &f\ \)It.( JE. I
1_/--1_1 I I
1_/_1_1 I \
1_/_1_1 I I
1_/_1_1 I \
1_/_1_1 I I
1_/_1_1 I I
CITY
W FvJ'1 I
U) ~'1-1
WH-J I
'1-1
I
I
\
I
I
ZIP
lu~O
J 'LSC1 0
i 2)'tf 0
SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF2 AUXILIARIES/AFFILIATES. EACH AUXILIARY/AFFILIATE LISTED MUST HAVE ITS OWN ID NUMBER.)
NAME OF AUXll..IARY/ AFFll1A TE
dAMES OF CHANCE ill NUMBER
R.l.GC.2A (Rev. 4/03)
Page 1 of2
\\\1\11 \ 11111111\ \11I11111111 ..J
,
r SC~~~~Pli~,,~~~~?'~~~~.~~~~:~n'!..<;'= ",,"P_IiR<dt~. . ~
member of applicant oCKanization or affiliate for at least I year. !
YEARS OF I
MEMBER NAME . DATE OF BlRm MEMBERSIllP STREET ADDRESS CITY I 1 ZIP
I_I _I _ I _ I I ~
1_1_1_1_1 1 ~l
I_I _I _ I _ I I ~
1_1_1_1_1 1 ~I
1_1_1_1_1 I ~I
1_1_1_1_1 I I
I I I I_I
r-I-I- I _ I I I
1~/=1=1_1 I I
1_1_1_1_1 I !I
1_1_1_'_1 I It,'
I I I '_I I
/-1-1-1_' I ~I
'-1-1-'_1 'i" II
'-1-1-1_1 I II
1=1=1_1_1 1 ~I
1_1_1_1_1 I ~,I
1_1_1_'_1 I ~I
1_1_1_1_1 I il
1_1_1_1_1 I fl
I_I _I _ , _ I I ~ I
I I I I_I I .~I
/-1-1-'_' I I
I-/~/-I_I I I
'-1-1-'_' I I
1=1=1=/_1 I fl'
I I I I_I I I
'-1-1-'_1 I rl
'=1=1= I_I I' II
1_1_1_1_1 1 II'
I I I I_I I I
1=1=1='_1 I I,
I I I '_I I II
'=1=1=/_1 I II
, RT.r.r..2A (Rev. 4103)
Attach additional sheet if necessary.
P!llJ~ ? of?
11111111111 111111 II III 111111 I
I
GC-5
I
LICENSE TO CONDUCT
GAMES OF CHANCE
PLEASE CHECK
GAMES OF CHANCE 0
BELL JAR r&-
RAFFLE 0
GC - [iE] - GIiliJ- [iliJi] - ~
N.Y.S. Identification 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
$1 25.00 II I
Amount of Fee Paid Lessor's License Number
Address: 2 East Main Street City: Wappingers Falls
Entire net proceeds to be devoted to the following specific lawful purpose(s):
Charitable Donations, Maintenance of Building.
Names of Members in Charge
James O'Connor
Zip Code:
12590
John Simons
John Gorman
LICENSE PERIOD
DATE
Year 2005
DAY OF WEEK
HOURS
TYPE(S) OF GAMES
Bell Jar
RAFFLE DRAWING
DATE
DRAWING TIME
DRAWING LOCATION
AMOUNT OF RAFFLE PRIZES (Cas~ or Merchandise Prizes
at Fair Market Value)
I THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
I 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)
EACH WHEEL
THE TOTAL AMOUNT OF PRIZES FOR EACH BELL JAR
DEAL SHALL NOT EXCEED $3,000 AND NO SINGLE PRIZE
SHALL EXCEED $500.
NUMBER OF WHEELS
GAMES SHALL BE PLAYED IN ACCORDANCE WITH
STATE LAWS AND RULES AND LOCAL ORDINANCES OR
LAWS.
Issued by
TOWN OF WAPPINGER
(Name of Municipality)
January 12, 2005
(Date)
~rC~ERK. <. .'
.;~~e'tf'?4:w~
""" ..}ll't.tI
L BJ-GC-5 (Rev. 4/03)
(Signature :Autho zed Officer)
111111111111111I1111111111111 ~
I
GC-2B APPLICATION FOR GAMES OF
NYS RACING & WAGERING BOARD CHANCE LICENSE
1 Waterv1iet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
-,
[IQ]/IAJql/lo\41
Date
SCHEDULE 5 DATES, HOURS AND RENT OF ALL LICENSE PERIODS TO BE HELD
(NOT APPLICABLE FOR BELL JAR. GAMES)
DATE HOURS RENT
, f . ,f . I am /pm - am / pm !$,
'- . . . I . . , I . . . ia,
./. / I am / pm - .am/pm ! $.
"- . , . , . . . . . I . . . '
./. , f . I am / pm - am / pm !$.
"--- . . . . . . , . . . . , ,- .
, f . ,f . I ,am /pm - ,am/pm! $.
"- . , . ' -, . I. , 1-'
, f . ,/ , I am /pm - ,am/pm!$ .
, . . . . . . . . . . I. .
, f . ,/ . I ,am / pm - ,am/pm! $.
, . . . . . ,., ,-,
" f . . f . I am / pm - ,am/pm! $.
.. . , . . . . . .
./. /. I am / pm - .am/pm! $.
, , . . . . , . ,8 . ,-,
./. . /. I am/pm - ,am/pm! $.
"--- . , . .. . , ,- . ,. L
./. , / . I am / pm - ,am/pm! $.
"-- . , . , " , . ,- . ,.,
./. , / . I am / pm - ,am/pm! $.
'- . , . .. . , . . . . ,.,
./. , f . I am / pm - ,am/pm! $.
-'-- t . . . . . . ,- . . .
RAFFLES PRIZES (Cash or Fair Market
DATE TIME
I Value of Merchandise)
I. .f am / pm - am / pm i$. . . . . ,". .
. . I . .J . . , . . . . ,
, I , .f 1 am / pm - am / pm !$,
"--- . . . I . . " , J . . , I. 1
f .f I am / pm - am / pm \$.
. . , I . t. , , . . . , ' "
,I ,f I am / pm - ,am / pm 1$.
. . I . I. . , I. . ......
.f ,f I am/pm - am / pm \$.
~ . I . t . , 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 of2
\\1\1\ \ \\1 \1 \11\\ \ I \1\\\1 \11\ .-J
!
r SCHEDULE 7 TYPES OF GAMES.I '-,
List all of the single types of games to be conducted at all license periods enumerated in Schedule 51
Note for Ve28s Ni2hts and Bazaars only: The total amount of prizes during anyone license perioh shall not
aggregate more than $400 for each single type of game of chance when five types of games of chan~e are to be
conducted during anyone license period. The total amount of prizes during anyone license period ~hall not
aggregate more than $500 for each single type of games of chance when less than five single types 9f 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 MAXJMUM AMOUNT OF PRIZES
TO BE AWARDED FOR EACH E OF
GAME OF CHANCE (GAME B K)
at $
at $
at $
at $
at $
For Merchandise Wheels, Bell Jars and Raffles, please complete the appropriate spaces below.
MERCHANDISE WHEELS:
BELL JAR:
THE TOTAL AMOUNT OF PRIZES ~R
EACH MERCHANDISE WHEEL SH L
NOT EXCEED $10,000 AND NO SIN LE
PRIZE SHALL EXCEED $250 I
I
I
THE TOTAL AMOUNT OF PAY~UTS
FOR EACH BELL JAR DEAL SHALL NOT
EXCEED $3,000 AND NO SINGLE P IZE
SHALL EXCEED $500 !
!
!
INDICATE NUMBER OF
MERCHANDISE WHEELS
(NO LIMIT)
INDICATE IF THIS APPLICATION
IS FOR A BELL JAR
LICENSE
YES):( NO 0
RAFFLES:
INDICATE IF THIS APPLICA nON
IS FOR A RAFFLE
LICENSE
YESO NO 0
IF YES, LIST RAFFLE DATES, TIME(S)
OF DRA WING(S) AND PRIZES IN
SCHEDULE 5
H T.r.r.2R mev. 4/03)
Pcl!:W 2 of 2
THE TOTAL AMOUNT OF PRIZES "OR
ALL THE RAFFLES CONDUCTED >DR-
ING THIS CALENDAR YEAR S 'ALL
NOT EXCEED $100,000. NO S GLE
PRIZE SHALL EXCEED $5 ,000
EXCEPT THAT A SINGLE P ~ OF
$100,000 MAY BE AWARDED IF SO
INDICATED IN SCHEDULE 5 !
I
11111111111111111111'11111111 ~
!
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 CHAN'CE
LICENSE:
GC - GEl- GJillJ - GIiliJ - ~
N.Y.S. Identification Number
Town of Wappinger
Name of Municipality
Dutchess
2 East Main Street, Wa ingers Falls, New York 12590
Address
After investigation, and a hearing if required under Sec. 192
have been made:
1. All the members-in-charge designated in the pli
character and have never been convicted 0 a cr'
Signature of Person Conducting lnvestigatio
~s
.::::-' ' rr
,-) ~._Kl'\\l
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
,v/A
tI/t1-
~Yes DNo
/KJ Yes DNo
~Yes DNo
~Yes DNo
18 Yes DNo
.f8J Yes DNo
~Yes DNo
t:j Yes DNo
DYes 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 12/30/ 2004 Authorized Officer
Date
1///f/tJ 5
, I
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~ (Jill. 4103) 1\1\\ 1111111\\\\ \1\\ \\111111\ ~