Wappinger Eks Bell Jar
~. ..-
TOWN OF WAPPINGER
TOWN CLERK
CHRIS MASTERSON
SUPERVISOR
JOSEPH RUGGIERO
TOWN CLERK'S OFFICE
20 MIDDLE BUSH ROAD
WAPPINGERS FALLS, NY 12590
(845) 297-5771
FAX: (845) 298-1478
TOWN COUNCIL
VINCENT BETTINA
MAUREEN McCARTHY
JOSEPH P. PAOLONI
ROBERT L. VALDATI
February 2, 2006
Dutchess County Commissioner of Finance
22 Market Street
P()ughkeepsie, New York 12601
Subject:
ADD'L. LICENSE FEE - GAMES OF CHANCE
Enclosed is a check in the amount of $38.41 made payable to the D. C. Finance
C()mmissioner from the Wappinger Elks Lodge #2609, Town of Wappinger, for an
"additional license fee" for Games of Chance activity that took place on 11/04/05.
CJJl-Cftf~
~hn C::. Mas;erson
T()wn Clerk
T()wn of Wappinger
dg
i.t.
""->
50-235552
WAPPINGERS LODGE #2609 BPOE OF THE USA INC. 219
P.O. BOX 47 6801484113
WAPPINGERS FALLS, NY 12590 DATE $3J~
115
PAYTOTHE ""7),,}.-o L , /).,.-- ./ ~ I $ :? 0 IL J
()j{IJEROF .,Ir'w 1c-//e.>:;J Lo:-u ,A.' ~) v-'./,/" 4A'c::.e V:../~~, (f/v"';;z...... Q<:1, r .
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--~/--ft,--1~L~' II/"~_.....___. _..~""..
THE
BANKOI<'
~~W 48 Vassar Road
"YOM Poughkeepsie, NY 12603
- .---98tLARS ~
MEMO
f!J}c,~ 7P~
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GC-7
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
INSTRUCTIONS: Prepare report in triplicate. Within 7 dayS after each license period, send original to clerk of municipality, send one copy to
N. Y.S. Racing & Wagering Board, Bureau of Bell Jar & Charitable Gaming Compliance, I Watervliet Ave. Ext., Suite 2, Albany, NY 12206-1668,
and retain one copy for your files. Where applicable, one copy shall also be submitted to the Chief Fiscal Officer of the County.
FINANCIAL STATEMENT
OF GAMES OF CHANCE
OPERA nONS
(Please Print or Type)
Name of Organization
11 ~ ~VI/T€ 37lP {)fill/NGli. fi1J..l5
Street Address Municipality
Address Where Games are Conducted, if Different:
/dS-9o
Zip
iJ V Ie hJf'SS
County
Street Address
Zip
[ill] I ~ I @EJ
Date of License Period
County
Number of Players
A. RECEIPTS-
1. Admissions (if fee is charged).............................................................................
2. Profit or Loss from games other than Merchandise Wheels................................
3. Profit or Loss from Merchandise Wheels............................................................
(Form GC-7B must be completed and attached)
t
Hours of License Period
4. Total Receipts (Add Items 1, 2 and 3)................................................................
B. EXPENDITURES - (Show only payments actually made)
Describe Expenditure Payee
Check No.
2. License Fee
3. Games of Chance Equipment
and Supplies
B,,~ fiCCfUh/i/m
/0(,
$
$
$
$
$
$
6
0
.3 l3
I .3 t,
q 1/
7 & B
3 8
7 ~9
o.~
c:li~ .~
. [QIQJ
. [Q]8J
.Is IS'I
.~
.18 151
. [2liJ
. [ill]
. [ill]
1. Rent
4. Services
5. Other Expenses E~()Jf. ,efffJ Ii. /30 h /J CCfLl/l}/,IJ
i1{J[t L.tC~;i:J'€ /J()h k'fiMlJJm
6. Total Expenditures...... ........................................ ......... ........................................ $
C. NET PROFIT OR (LOSS) $
1. Profit or (Loss) Before Additional License Fee (Item A41ess Item B6)...............
2. Additional License Fee (llST CHECK NUMBER )..................... $
3. Net Profit or (Loss) (Item 1 less Item 2)............................................................... $
D. GAME BANK FUND Payee Check No. Amount
(Memo Entry Only) loLli r.1f AtlTc k 17;' i / IJ 7 of) , 00
E. DISPOSmON OF AND ACCOUNTING FOR NET PROCEEDS -
1. If this is organization's first license period, give opening balance, if any, in the $
Special Games of Chance Account................................. ..... ....... ..........................
Source of opening balanceS
2. Unexpended balance of net proceeds shown on last report.................................
L BJ-GC.7 (Rev. 4/03) Page 1 of 2
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Amount
7. Total Disbursements............................................................................................ $~. @IQ]
8. Unexpended balance of net proceeds (Item 6 less Item 7)................................... $ . {P.3 . ~
(Include interest bearing accounts)
F. Reconciliation of Unexpended Balance (To be Completed Monthly - - Upon receipt of Monthly Bank Statement)
Depositorv Name of Bank Account No. Reconciled Balance
1) Checking Ilh,d- c;I) J.l.'f. &8oit./8"f1/3 # ~ t 37. Lf~
2) Savings
3) Other
Total (Must be the same as Line E8 - Unexpended Balance)............................... $
Instructions: This section must be fully completed by aU parties.
I swear, or affirm that the information and statements contained herein have been examined by me and to the best of my
knowledge and belief are true, correct and complete.
tJO':C),E~ 5
County
[ill2J I [ill] 1m
Date
J:).. q LA-Nil
Street Address City
(~)~-~
Phone Number
Pre er (if different):
o 8 l Il I
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Street Address City
(~)1~19U]-~
Phone Number
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County
@ill I [[]]] I @]I]
Date
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Zip ._ J!
~~
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County
[RZ] I lTIZJ I rn
Date
L BJ-GC-7 (Rev. 4103)
Page 2 of2
11111111111111111111111111 .J
r
GC-7B
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
CASH CONTROL REPORT
GAMES OF CHANCE
J
71
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@.0
Organization: WI>Pt/11(;i:tl 11 Llcs La f" ~ J..(Po? 1.0. No.: /3 - 02/9 -t,()~ -O)j)13 Date of License Period:czm / ~ / 05-
;:;e
- . . .-.-., '." -
Type of Game Type of Game Type of Game Type of Game Type of Game CONTROL SUMMARY
No. 1 I3kk~1X /<.- No. 2,J1~1l ~t.ft. No.3 f1le SIX No.4 No.5 PROFIT OR (LOSS)
Number of Number of Number of p Number of Number of (A) - 1J7JJ.oo
Locations CO Locations I Locations Locations Locations Game No. 1
.
Starting Starting Starting Starting Starting (B) - IS,;} ,I) 0
Game No.2
Bank ____~_~-'Jl 0 _ Bank /00 ,()o Bank Bank Bank
(C) -
Ending Ending Ending Ending Ending Game No.3 '- (,) -
Bank Jj 1/ .00 Bank :l5~t 00 Bank Bank Bank
(D) -
Profit or Profit or Profit or Profit or Profit or Game No.4 .... 0 -
(Loss) 711. 0 () (Loss) /SJ...() 0 I (Loss) (Loss) (Loss)
(A) (B) (C) (D) (E) (E) -
Game No.5 -0 -
ENTER PROFIT OR (LOSS) FOR EACH TYPE OF GAME ON CORRESPONDING LINE OF CONTROL SUMMARY
WORKERS WORKERS WORKERS WORKERS I WORKERS
Net Profit 1/81;,3,0 ()
(SJZ1Z !-JST) I or (Loss)
/.) . ~ i)-do' {IJ
(Enter on Line A-2 of GC-7)
-------.------.,,-.......,..-......-,.--- --~---
RoAlftJ /kd(tI/'JiJ 1m
L BJ.GC.7B (Rev. 4/03)
Page 10f2
Prepared By
111111111111111111111111111 --1
----r_
'"
. Scbedule 4. Assistants to Members in Charge of Games
First MI
Frank
Philip A.
Ralph J.
Henry J.
Harold A.
Francis J.
Roger
Richard O.
Richard D.
Stephen F.
Robert
Mark H.
Harris C.
Robert J.
Joseph
William K.
Eugene P.
Rosemarie
Gregory F.
Kenneth J.
Robert N.
Last Name
Abato
Abbate
Anzivina
Boldnn
Crawford Sr.
DeGano
DeJordy
Desruisseau
Dobbins
Drobnak
Fischetti
Fox
Jones
Ju1iano
Jurina
Minkowski PSVP
Pampa lone
Perretta
Sarno
Tucker
Wallner
DaB Address
04/24/1940 39 Kensington Drive
05/16/1937 6 Hackensack Hghts Rd
12/21/1935 12 Thoms Lane
01/11/1936 28 Gold Road
02/23/1936 318 Sunset Hill East
07/18/1946 27 Brandy Lane
09/19/1944 83 Kent Road
11/05/1936 183 Red Cardinal Court
05/30/1949 6 Schuele Drive
02/02/1957 53 Moccasin View Rd.
06/07/1926 91 Ardmore Drive
09/15/1957 28 Tiger Road
04/24/1944 217 Brothers Road
10/05/1953 2776 West Main Street
02/28/1963 173 Hillside Lake Rd.
03/20/1942 427 McGrath Blvd.
09/03/1936 53 Helen Drive
09/07/1943 35 Cathy Road
07/01/1936 13 Dana Place
03/19/2029 34 Pawling Lake
01/17/1933 7 Kinry Road
Town
Hopewell Jet
Wappingers Falls
Highland
Wappinger Falls
Fishkill
Wappingers Falls
Wappingers Falls
Poughkeepsie
Wappingers Falls
Fishkill
Wappingers Falls
Hopewell Jet.
Stormville
Wappingers Falls
Wappinger Falls
Fishkill
Wappingers Falls
Poughkeepsie
Wappingers Falls
Pawling
Poughkeepsie
Yrs an Elk
8
15
18
12
15
15
15
18
19
6
25
11
15
10
7
25
17
5
25
6
16
r MERCHANDISE WHEELS 71
t. _
Merchandise Wheel No.1 Merchandise Wheel No.5 Merchandise Wheel No.9 CONTROL SUMMARY
Receipts (Less change bank) Receipts (Less change bank) Receipts (Less change bank) PROFIT OR (LOSS
Less: Value of Mdse. A warded Less: Value of Mdse. Awarded---- Less: Value of Mdse. Awarded (A) - Mdse.
Wheel No. 1
Profit or (Loss) Profit or (Loss) Profit or (Loss) (B) - Md
(A) (E) (I) Wh 0.2
I - Mdse.
. Wheel No.3
Merchandise Wheel No.2 Merchandise Wheel No.6 Merchandise Wheel No. 10 I (D) - Mdse.
Wheel No.4
Receipts (Less change bank) Receipts (Less change bank) (E) - Mdse.
Wheel No.5
Less: Value of Mdse. Awarded Less: Value of Mdse. Awarded (F) - Mdse.
Wheel No.6
Profit or (Loss) (B) Profit or (Loss) (F) (J) (G) - Mdse.
Wheel No. 7
(H) - Mdse.
Merchandise Wheel No.3 Merchandise Wheel No.7 Wheel No.8
(I) - Mdse.
Receipts (Less change bank) Receipts (Less change bank) Wheel No.9
(J) - Mdse.
Less: Value of Mdse. Awarded Less: Value of Mdse. Awarded Wheel No. 10
(K) - Mdse.
Profit or (Loss) Profit or (Loss) Wheel No. 11
(C) (G) (K) (L) - Mdse.
Wheel No. 12
Merchandise Wheel No.4 Merchandise Wheel No. 12
Receipts (Less change bank) Receipts (Less change bank) Receipts (Less change bank) Net Profit
or (Loss)
Less: Value of Mdse. Awarded Less: Value of Mdse. Awarded
(Enter on Line A-3 of GC-7)
Profit or (Loss) Profit or (Loss)
~ ~ ~
PROFIT OR (LOSS) FOR EACH TYPE OF GAME ON CORRESPONDING LINE OF CONTROL SUMMARY
Page 2 of 2
11IIII111111111111111111111 --.J
r
GC-S
I
LICENSE TO CONDUCT
GAMES OF CHANCE
PLEASE CHECK
GAMES OF CHANCE 0
BELL JAR .
RAFFLE 0
GC - CiIJ - [2IW].. GJill- [UQIilill
N.Y.S. Identification Number
NYS RACING & WAGERING BOARD
1 WatervIiet 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/ I
Amount of Fee Paid Lessor's License Number
Address: 1195 Route 376 City: Wappingers Falls
Entire net proceeds to be devoted to the following specific lawful purpose(s):
Charity, Patriotic, Youth Activities, Educational
Names of Members in Charge
Dana Mills
Zip Code: 12590
Joan Mills
Stephen Drobnak
Richard Desruisseau
UCENSE 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~ Of Merchandise Prizes
at Frof Market Value)
THE MAXIMUM AMOUNT OF PRlZES 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
TOWN OF WAPPINGER
(Name of Municipality)
April 27, 2005
(Date)
11111111111111111 II1I1II1II11 ~
L BJ.GC-5 (Rev. 4/03)
r'
GC-6
NYS RAONG & W AGERlNG BOARD
I Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
APPLICA TION TO AMEND
(pLEASE CHECK)
GAMES OF CHANCED
BELL JAR ".
RAFFLE 0
-,
Must be conspicuously displayed along with License (GC-5)
(FOR OFFICE USE ONLY)
$1 ~
Fee Received
(only ifapplicable)
I ~~&lp5 I
Dae
GC-.[JJlJ-0Il1]-~- ~ 05Z'3
N.Y.S. Identification Number Present License Number
INSTRUCTIONS: PLEASE FILE THREE SIGNED COPIES WITH MUNICIPAUTY
37& WI) f fJ)JJeeR. r,() Us /;lS1o f)iJ'lchlf5:S
Municipality Zip County
4.l/)fJ I' hJC?f Ii. ~/)LlS /plS90 Ih/ICh/S5
Municipality Zip County
Application is hereby made to amend the above numbered license. The amended information is contained in the schedules which are
checked below and auached, and are to replace the schedules previously filed.
~'schedule I.
~~Schedule 2.
o Schedule 3.
o Schedule 4.
o Schedule 5.
o Schedule 6.
o Schedule 7.
Officers And Directors
Members In Charge Of Games
Auxiliary/Affiliate Organizations Assisting At Games
Assistants To Members In Charge Of Games
Dates, Hours And Rent Of All License Periods To Be Held
Expenses
Types of Games
If any other information furnished on original application is to be changed. show amended data below.
L BJ-GC-6 (Rev. 4103)
Page 1 of2
111I111~n11UIIIIII .J
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I
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
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, wiD 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.
S. 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 N.Y.S. Racing and Wagering Board.
[QEJ/[QliJ/[illf
Date Si
s ~eh c '"' (" 1)l<ol3/(/A f
PrintN me
OF NEW YORK }
COUNTY OF ::D u -r c.. H~ S5
CITYITOWNIVILLAGE OF ~J A ff {1IJr;,.E R ~ 55
....51t:-rtI f-JJ r: ~ t> IJ II A k 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 ani!(~"t ($.)he has personally
affixed his (her) signature to this affidavit. (ltP!"\~~' ..... '((v".
~:::ztiJ1, day of ~. 20 ~ "good o:,:,;:~"', '<.'~
Notary Public Commissioner of Deeds
My Commission expires ~-,. '3 r , 20 ~
STATE
To be completed by Municipal Clerk:
Issued by
-ltJwtl Or 1lJ11,.4//NGE~
(Name of Municipality)
L BJ-GC-6 (Rev. 4103)
Page 2 of2
IUlllnn~11 .-J
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"
Schedule 1: Officers and Directors
WAPPINGER LODGE #2609 OFFICERS for 2005-2006
Title Name Address Town Zip DaB
---------------------- --------------- -------------------------- ------------------------------ ------------------------------ ----------, --------------------.
Exalted Ruler Steve Drobnak 53 Moccasin View Rd. Fish kill 12524 02102/1957
Leading Kgn Pamela Kultsar 58 Hillis Terrace Poughkeepsie 12603 02/01/1950
LoyalKgn Derrick Mills Pawling Lake Box 17 Pawling 12564 10/10/1940
Lect. Kgn Sandra Seekamp 67 Pawling Lake Pawling 12564 12/10/1945
Esquire Mark H. Fox 28 Tiger Road Hopewell Jct. 12533 09/15/1957
Chaplain Diana M. Cole P.O. Box 549 Hughsonville 12537 04/25/1948
Inner Guard Rosemarie Perretta 35 Cathy Road Poughkeepsie 12603 09/07/1943
Secretary Robert M. Acquanita 10 Vorndran Dr. Wappinger Falls 12590 OS/25/1942
Treasurer Richard O. Desruisseau 183 Red Cardinal Court Poughkeepsie 12603 11/05/1936
Tiler Jacqueline Alfano 93 Brothers Rd. Wappinger Falls 12590 08/27/1938
Trustee Patrick J. Moriarty 26 Robert Lane Wappinger Falls 12590 04116/1941
Trustee Paul U. Bader 366 Andrews Rd. Lagrangeville 12540 09/20/1965
Trustee Harris Jones 102 Brothers Road Stormville 12582 04124/1944
Trustee Gerhard P. Stoetzel 662 Noxon Road Poughkeepsie 12603 05/02/1942
Trustee Joseph Jurina 173 Hillside Lake Rd. Wappingers Falls 12590 02128/1963
No Officer receives compensation of any kind.
Schedule 2. Members in Charge of Games
LAST_NAME FIRST _MI ADDRESS
---------------- --------------- ------------------------------
Mills Dana Pawling lake Box 17
Mills Joan Pawling lake Box 17
Drobnak Stephen 53 Moccasin View Rd.
Desruisseau Richard 183 Red Cardinal Court
City
Pawling
Pawling
Fish kill
Poughkeepsie
~#
Zip DOB Yrs Member
---------- ------------- -------------
12564 02/18/1971 2
12564 06/26/1944 3
12524 02/02/1957 7
12603 11/05/1936 19
{
r
GC-4
NYS RACING & WAGERING BOARD
1 Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
-,
FINDINGS AND
DETERMINA TION
FOR GAMES OF CHAN'cE
LICENSE
GC - rn - [ilil2J - GI2IiJ - CillLJLD
N.Y.S. Identification Number
TOWN OF WAPPINGER
Name of Municipality
DUTCHESS
1195 Route 376.
Address
Wappingers Falls,
New York
12590
After investigation, and a hearing if required under Sec. 192 of!J;te General Municipal Law, the following findings and determinations
have been made: ./
/;-'
1. All the members-in-charge designated in the ap ca:oti to con ct g of ce .of good moral ~es 0 No
character and have never been convicted of a ri / / '
Signature of Person Conducting Investigation
Title
S h.e" tt- .
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)
IXI Yes DNo
IXI Yes DNo
~Yes DNo
~Yes DNo
KI Yes DNo
KI Yes DNo
KI Yes DNo
IX] Yes DNo
n/a DYes DNo
.~~
TO BE COMPLETED BY MUNICIPAL CLERK:
As a result of the findings and determinations stated above, license is GRANTED , license is D
Signature of
Authorized Officer
Filing date of Application April 13, 2005
Date ~tJ ~------- Title TOWN CL
ONE COpy ~F 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.
11111111111111111111111111111 -1
L BJ-GG4 (Rev. 4/03)
I
GC-4
NYS RACING & WAGERING BOARD
1 Waterv1iet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
FINDINGS AND
DETERMINATION
FOR GAMES OF CHANCE
LICENSE
-,
GC - [ill- [Uili] - GI2IU - CiliI!J1IJ
N.Y.S. Identification Number
TOWN OF WAPPINGER
Name of Municipality
DUTCHESS
1195 Route 376.
Address
Wappingers Falls,
New York
12590
After investigation, and a hearing if required under Sec. 192 o:JPe General Municipal Law, the following findings and determinations
have been made: . /" .--..?
1. All the members-in-charge designated in the ap C;-ti6n ~o con ct ga of'of good moral R'Yes 0 No
character and have never been convicted of a riJJlt(/ .
Signature of Person Conducting Investigation
Title
s he I\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.
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)
IX! Yes DNo
IX! Yes DNo
<<J Yes DNo
Kl Yes DNo
Kl Yes DNo
KJ Yes DNo
KJ Yes DNo
!XI Yes DNo
n/a DYes DNo
TO BE COMPLETED BY MUNICIPAL CLERK: ./
As a result of the findings and determinations stated above, license is GRANTED ~cense is D
Signature of
Filing date of Application April 13, 2005 Authorized Officer
Date ~ ;/& .~----- Title TOWN CL u'
ONE COpy ~F TH 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) 11111111111111111111111111111 .-J
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
April 13, 2005
Adrian Anderson, Sheriff
150 North Hamilton Street
Poughkeepsie, NY 12601
Subject:
Amendment of OfficerslMembers for Bell Jar License
Dear Sheriff Anderson:
The Wappinger Elks # 2609, has submitted an "Application to Amend" their
Bell Jar license #0503 which was granted January 25,2005.
A list of "Officers / Directors" and "Members in Charge of Games" is enclosed for
your review. Please complete the "Findings and Determination" form attached and
return the completed form to my office.
Thank you for your attention to this request.
Yours truly,
A'// ~i v1/fh/ /'" J .J J
./ VU~/. //1 p--
Gfi>ria J. 0 e
Town clirll
Town of Wappinger
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GC-2
NYS RACING & WAGERING BOARD
j WatervIiet 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 ~
RAFFLE 0
FOR OFFICE
USE ONLY
$1 ';.5,~.:!.
Fees Received
cmJ / [2EJ / I 0151
Date
Municipal License Number
INSTRUCTIONS: PLEASE FILE THREE SIGNED COPIES WITH MUNICIPALITY
GC- [ili] - 02J[]- ~- ~
N.Y.S. Identification Number
IT IS A MISDEMEANOR TO MAKE ANY FALSE ST A 1'P-
/0 W tJ 0 r 1t}.4;:> r>.LV? &7t I D 6
Name of Municipality .. II j {;
1.
2. Address
;('1
J)y.5,-
3. Has applicant ever been denied a i.
4. Check type of organization and, if ap!
Corporation lit
Incorporated Association
o
Unincorporated Association 0
Individual
o
5. Did your corporate status change since your i,
.>.;;ned? 0 Yes 0 No
LICATION
S,(
Stall
j ,7'~
uJ"<JY/ ) P' ,p.Y' U /'
~ C rf'(~ c1 tA- 0 )1 uf 0 ~ ,
fr"A1 '/
-=rIIIJ
/26-j' cJ
.,heet if necessary)
State in
~/I?I/I
_Leu] / CD / CD
6. Are you doing business under a trade name? 0 _ ,LJ 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/ IS- /?o '" I c='
8. Name and address of authorized games of
chance lessor renting to applicant.
37? 4/?/T U;//~/f
/;..51'"
J/j;;
9. Does the applicant own the premises? MYes 0 No If "yes", how long?
L BJ-GC-2 (Rev. 4/03)
.;20 yte.S I
Page 1 of 2
11111111I111111111I1111111111 .-J
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.RT C. PURPOSES OF GAMES
14. State the specific purposes for which the entire net proceeds are to be devoted and in what manner.
CII~..cTY) ?1f7;LrOTEC!. / )/IJVt-1J /k.TTrr~ I
wear (or affirm):
EOi/MT1~
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 i
contained in this application are a material part hereof. i
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 Ga I es of
Chance Licensing Law and the Rules and Regulations of the Board. ' 1
I
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 he~d,
operated and conducted, who is familiar with the Games of Chance Licensing Law, the Rules and Regulations of the N.Y.S. Racing & Wage1ng
Board and local licensing ordinances or laws, will be present at all times, in charge and primarily responsible for the conduct of games. I '
I
That the undersigned will be responsible for the holding, operation and conduct of all games of chance in accordance with the terms of the lii'ense,
the provisions of the Games of Chance Licensing Law, the Rules and Regulations of the N.Y.S. Racing & Wagering Board and with the prov sions
of local licensing ordinances or laws.
I
,
That the undersigned has read and is familiar with the provisions of the Games of Chance Licensing Law as amended, the Rules and Regulatibns
of the N.Y.S. Racing & Wagering Board, and the local licensing ordinances or laws.
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.
9ZJ/[LN]/~
ate
'7IJ<~/ S (!. J:> I ~S
Print Name
OF NEW YORK }
l.... '
'.
COUNTY OF \ u.;.5 SS
CITYffOWNNlllAGE OF~D,~d)(\d-l ,~
~R..lS c:., jCV\..e,4- being duly sworn deposes and says that (s)he is the person above named,
at (s)he has read the foregoing statement and the answer therein noted, and that such answers are true and that (s)he has personall~
fixed his (her) signature to this affidavit. i
~
Nom to before me this \4 -
STATE
day i~, 20 O(
Signed ~
r-
Commissioner of Deeds
Notary Public
y Commission expires S. lO
,20~
-- -- .- .- .-
MARIE PilON
Notary PubliC. State of New York .
NO. 01 PI61 09533
Qualified In Dutchess County ~ ~
My Commission Expires :\ . I D . Qj ~
BJ.GC.2 (Rev. 4/03)
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Page 2 of 2
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GC-2A
APPLICATION FOR GAMES OF CHANCE LICENSE
>1YS RACING & WAGERING BOARD
I Watervliet Ave. Ext., Suite 2
\lbany, NY 12206-1668
felephone (518) 453-8460 Fax (518) 453-8492
'1WW .racing.state.ny. us
p.l-JJ&e,
Name of Organization
GC-[LliJ-~-~-~
NYS Identification Number
CHEDULE 1: OFFICERS AND DIRECTORS
st names, addresses and dates of birth of all officers.
organization is a corporation, or an incorporated or unincorporated association, list officers and directors.
TITLE NAME DATE OF BIRTH STREET ADDRESS CITY ZlP
eili~ r~;<cJk 1I1J!2./L~ (I. ';;;leal~/.1 ~I Ill).. J3.ft.Gt~J ~ I 571?/11v';/!e-1 i~-t:J-
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Attach additional sheet if necessary.
0LJ/DiJ/~
Date
CHEDULE 2: MEMBERS IN CHARGE OF GAMES
(MUST LIST AT LEAST FOUR MEMBERS OF APPLICANT ORGANIZATION)
DATE YEARS OF
NAME OF BIRTH MEMBERSHlP STREET ADDRESS
I 1 1 I I .
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iCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF 2 AUXILIARIES/AFFILIATES. EACH AUXILIARY/AFFILIATE LISTED MUST HAVE ITS OWN ID NUMBER.)
NAME OF AUXJLIAR Y/ AFFlLIA TE
GAMES OF CHANCE ill NUMBER
BJ-GC-2A (Rev. 4/03)
Page 10f2
111111111111111111\11\ 1II1111 --.J
.
-
I
GC-2A
APPLICATION FOR GAMES OF CHANCE LICENSE
-IYS RACING & WAGERING BOARD
I Watervliet Ave. Ext., Suite 2
\lbany, NY 12206-1668
relephone (518) 453-8460 Fax (518) 453-8492
'IWW .raci ng.state. ny.us
pJ-JJ&e
Name of Organization
GC- [LliJ - kiILE - 0iliJ - ~
NYS Identification Number
CHEDULE 1: OFFICERS AND DIRECTORS
st names, addresses and dates of birth of all officers.
organization is a corporation, or an incorporated or unincorporated association, list officers and directors.
TITLE NAME DATE OF BIRTH STREET ADDRESS CITY ZIP
eilJL re7);<~ JI/Qf2(2~S~, JOtlt% I~I .4f-1 .it.. I Iv), J3/!pr~.5 ~ I 5l7~t/I/1e.. I 1~-tJ-
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'1/1.u.J~-L I &uL- /1, Wc.9l- IlL 1-2-1 'UJ / 61"'-1 /31 IhIA~~ ~J I L~~rev/~ I~-Y;o
Attach additional sheet if necessary.
0LJ/[lli]/~
Date
;CHEDULE 2: MEMBERS IN CHARGE OF GAMES
(MUST LIST AT LEAST FOUR MEMBERS OF APPLICANT ORGANIZATION)
DATE YEARS OF
NAME OF BIRTH MEMBERSHIP STREET ADDRESS
1_/_/_1 I .
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J"/}t.71Jf?//~c! J?tM.--L I l::L 1 3 ~ I ~ I 9J (iL()tlJe4-~ /<.1
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,CHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF 2 AUXILIARIES/AFFILIATES. EACH AUXILIARY/AFFILIATE LISTED MUST HAVE ITS OWN ID NUMBER)
NAME OF AUXlLIAR Y/ AFFlllA TE
GAMES OF CHANCE ill NUMBER
BJ-GC-2A (Rev. 4/03)
-
Page 1 of2
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CITY
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ZIP
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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
member of applicant organization or affiliate for at least I year.
YEARS OF
MEMBER NAME . DATE OF BIRTH MEMBERSHIP STREET ADDRESS
I / / I 1
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B.l-GC-2A (Rev. 4/03)
Attach additional sheet if necessary.
Page 2 of2
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. 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
Name of Organization
GC- CD - []]] - []I] - []]]I]
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
't:.ffZ.-'C ! ~iq.< fl?"filA4ry,L:L/ /I- / <//!;I.t ;2d/;J&..lI w I ~ /!:21/J
I s rrd Ilf-t:;t. ~ J'1lJ&'12d-j I--LI .1=-1 .!f.1: I tlJ-. AMIl. I ~ .1V /).4(/3
f/lqt-r~ I t.P.!IP /P.r~L.o71i 1~/:bL/...u.1 J.tf 4bt'/f.nAl ~~,~fI/; I /2-"<)
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Attach additional sheet if necessary.
[D/[D/CD
Date
NAME
MEMBERS IN CHARGE OF GAMES
(MUST LIST AT LEAST FOUR MEMBERS OF APPLICANT ORGANIZATION)
DATE YEARS OF
OF BIRTH MEMBERSHIP STREET ADDRESS
1_1_1_1 1
'_1_1_1 I
1_1_1_1 I
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1=1=1=1 I
1_1_1_1 I
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1_1_1_1 I
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CITY
ZIP
SCHEDULE 2:
SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF 2 AUXll..IARIES/ AFFll..1A TES. EACH AUXll..lARY/ AFFll..IATE LISTED MUST HAVE ITS OWN ID NUMBER.)
NAME OF AUXILIARY/ AFFIllA TE
GAMES OF CHANCE ill NUMBER
L BJ-GC-2A (Rev. 4/03)
Page 10f2
11111111111111111111111111111 --.J
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 mu t be a
member of applicant orllanization 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
1_1_1_1_1
1_1_1_1_1
1_1_1_1_1
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1=1=1= I = I
1_1_1_1_1
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1=1=1= I = I
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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_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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L BJ-GC-2A (Rev. 4/03)
Attach additional sheet if necessary.
Page 2 of 2
CITY ZIP
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C-2B
'S RACING & WAGERING BOARD
vatervliet Ave. Exe., Suite 2
lany, NY 12206-1668
ephone (518) 453-8460 Fax (518) 453-8492
'W .racing.state.ny .us
APPLICATION FOR GAMES OF
CHANCE LICENSE
GC- [LliJ - [ill]f] - ~ - ~
NYS Identification Number
~HEDULE 5
G[]/[lli]/G0
Date
/ am / pm -
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/ ! ,am /pm -
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/ am / pm -
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/ I am / pm -
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/ I am / pm -
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\FFLES
DATE TIME
.! . .', ,am/pm - .'. .am/pm
I am / pm - am / pm
. J . ..., I...
I am / pm - am / pm
, I . .... ....
I am/pm - am/pm
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I am / pm - am / pm
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~HEDULE 6 1 J tt EXPENSES
st items of expb'6 e to be incurred, and the names and addresses of persons to be paid.
"'EM OF EXPENSE VENDOR NAME STREET ADDRESS CITY
-,-"I
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PRIZES (Cash or Fair Market
Value of Merchandise)
!$ , . . , ,', ,
!$,
!$.
1$.
!$,
,I,
. . .
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,.,
STATE
ZIP
BJ-GC.2B (Rev. 4/03)
Page 1 of2
11111111\111111111111\\111111 -.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 5.
Note for Vegas Nights and Bazaars only: The total amount of prizes during anyone license periOd~ s11 not
aggregate more than $400 for each single type of game of chance when five types of games of chance to be
conducted during anyone license period. The total amount of prizes during anyone license period shal not
aggregate more than $500 for each single type of games of chance when less than five single types of g mes of
chance are to be conducted during anyone license period. I
I
LIST THE MAXIMUM AMOUNT OF P~ES
TO BE AWARDED FOR EACH TYPE F
GAME OF CHANCE (GAME BANK
$ I
$ I
$
LIST NAME OF EACH TYPE OF
GAME OF CHANCE
(Limit: 5 Games)
at
at
at
at
$
$
at
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THE TOTAL AMOUNT OF PRIZES FORI
EACH MERCHANDISE WHEEL SHALL'
NOT EXCEED $10,000 AND NO SINGLE
PRIZE SHALL EXCEED $250
MERCHANDISE WHEELS:
For Merchandise Wheels, Bell Jars and Raffles, please complete the appropriate spaces below.
INDICATE NUMBER OF
MERCHANDISE WHEELS
(NO LIMlT)
BELL JAR:
INDICATE IF THIS APPLICATION
IS FOR A BELL JAR
LICENSE
YES ~ NO D
THE TOTAL AMOUNT OF P A YOUT$
FOR EACH BELL JAR DEAL SHALL NOt
EXCEED $3,000 AND NO SINGLE PRIZlf
SHALL EXCEED $500 i
I
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THE TOTAL AMOUNT OF PRIZES FOR
ALL THE RAFFLES CONDUCTED DUR.
ING THIS CALENDAR YEAR SHAL~
NOT EXCEED $100,000. NO SINOL ~
PRIZE SHALL EXCEED $50,00 )
EXCEPT THAT A SINGLE PRIZE 0
$100,000 MAY BE AWARDED IF sq
INDICATED IN SCHEDULE 5 '
Page 2 of 2 111111111111111111111111111'1 -.J
RAFFLES:
INDICATE IF THIS APPLICATION
IS FOR A RAFFLE
LICENSE
YESD NO D
IF YES, LIST RAFFLE DATES, TIME(S)
OF DRA WING(S) AND PRIZES IN
SCHEDULE 5
BJ.GC.2B (Rev. 4/03)
,---
GC-4
NYS RACING & WAGERING BOARD
1 Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
..
I
FINDINGS AND
DETERMINA TION
FOR GAMES OF CHANCE
LICENSE
GC - [ili] - [iliill - [ill]2J - GItiLGIJ
N.Y.S. Identification Number
Town of Wappinger
Name of Municipality
Dutchess
1195 Route 376. Wappingers Falls. New York 12590
Address
After investigation, and a hearing if required under Sec. 192 oVhe General Municipal Law, the following findings and determinations
have been made: /
1. All the members-in-charge designated in the applicat~Ji>6 to c9nduc rii~ f ch e are of good moral Mes 0 No
character and have never been convicted of a 'm ' ./. ..-
Signature of Person Conducting Investigation.
she\\f-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.
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 Garnes 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)
tljh
!rIff
rM' Yes DNo
IlZI Yes DNo
~Yes DNo
U<f Yes DNo
~Yes DNo
ISl Yes DNo
[8 Yes DNo
DYes DNo
DYes DNo
TO BE COMPLETED BY MUNICIPAL CLERK: .,
As a result of the findings and determinations stated above, license is GRANTED giicense is DE
, I~ Signature of
Filing date of Application III ~ ~ 5 Authorized Officer
. . / ~icipa1 c
Date j,~;r ~ Title
ONE C Y OF IS 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) 11111111111111111111111111111 -.J
I
GC-5
I
LICENSE TO CONDUCT
GAMES OF CHANCE
PLEASE CHECK
GAMES OF CHANCE 0
BELL JAR ~
RAFFLE 0
GC - rn - [il!liJ- GJill- CiliI!JLD
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: 1195 Route 376 City: Wappin~ers Falls
Entire net proceeds to be devoted to the following specific lawful purpose(s):
Charity, Patriotic, Youth Activities. Educational
Names of Members in Charge
Andrew Corti
Zip Code: 12590
Jacqueline Alfano
Richard Desruissenu
Harris C. Jones
LICENSE PERIOD
DATE DAY OF WEEK
YEAR 2005
HOURS
TYPE(S) OF GAMES
Bell Jar
RAFFLE DRAWING
DATE
DRAWING TIME
DRAWING LOCATION
AMOUNT OF RAFFLE PRIZES (Cash or Merchandise Prizes
at Fan Market Value)
THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
FOR EACH TYPE OF GAME OF CHANCE
$
NUMBER OF GAMES EACH GAME (Starting Bank)
THE TOTAL AMOUNT OF PRIZES FOR EACH BELL JAR
DEAL SHALL NOT EXCEED $3,000 AND NO SINGLE PRIZE
SHALL EXCEED $500.
THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
FOR EACH MERCHANDISE WHEEL
$
NUMBER OF WHEELS
EACH WHEEL
GAMES SHALL BE PLAYED IN ACCORDANCE WITH
STATE LAWS AND RULES AND LOCAL ORDINANCES OR
LAWS.
Issued by
TOWN OF WAPPINGER
(Name of Municipality)
January 25, 2005
(Date)
L/
)
~
Officer)
I 11111111111111111111111 .J
L BJ.GC-5 (Rev. 4/03)
,-
GC-2
-,
Municipal License Number
APPLICATION FOR:
PLEASE CHECK
GAMES OF CHANCED
BELL JAR ~
RAFFLE 0
$1 ~.5~~~
Fees Received
NYS RACING & WAGERING BOARD
j Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
FOR OFFICE
USE ONLY
0ZJ / [ill] / I 0151
Date
INSTRUCTIONS: PLEASE FILE THREE SIGNED COPIES VVITH MUNICIPALITY
GC - [ili] - [2I2EJ- ~- ~
N.Y.S. Identification Number
IT IS A MISDEMEANOR TO MAKE ANY FALSE STATEMENTS IN TillS APPLICATION
/0 w AI 0 r IV /-ff/ P .J:.;<J1j i31t U 1/ Ie. /res ~
Name of Municipality . . County
PART A. GENERAL
1. Name of Or anization
/Jfl~f~
2. Address
J7~
2
aI /fP pJ:.lfJft::7L- !i41/s.;.NY /~f' t.J
DYes ~No If "yes", why? (Attach extra sheet if necessary)
/JY.r
3. Has applicant ever been denied a games of chance license?
4. Check type of organization and, if applicable, give the State and date of incorporation.
Corporation lit
Incorporated Association
o
State incorporated
;(e l() ~ rz-!<
Date [2]f] / 02J / I cf'11 I
DateITJ/ITJ/ITJ
Unincorporated Association 0
State incorporated
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 iXfNo 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. I; fS- /futilE' 3 7? ~/#V'r ~/~f
/J.:>!"
8. Name and address of authorized games of
chance lessor renting to applicant.
J!jIf
9. Does the applicant own the premises? ~ Yes 0 No If "yes", how long?
.2 0 ,/JeS I
10. Capacity for public assembly ofprernises presently owned or occupied. .:3,/0
11. Have premises been regularly used? ~ Yes 0 No If "yes", how long? I/YI'<.S '
, ,
Are games of chance. being played now on these premises or has it ever been? DYes 0 No If "yes", give full details.
Vt:.,115 ;()14TS QMI JJWJoj",<~ · #LI4~P.! #~ #>#''-' Ii€ BB.4 - ~::w,;"
12. Are the premises or any part thereof If "yes", state tile type.oflicense and number.
where games of chance are to be played ~ Yes 0 No . /JI L L . L . - ~ '7\ /J'L ~
licensed by the State Liquor Authority? (jilt;) I <{1M... le~'t:" .:cObS 2. ~IITe. c.:,,,Y2!t3
13. Has such license ever been If "yes", why? (Explain on a separate sheet, if n~cessary, and attach.)
revoked or suspended? 0 Yes WNo
BJ-GC-2 (Rev. 4/03)
Page 1 of2
IlllllllllllIllllllllllllllIl ~
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.RT C. PURPOSES OF GAMES
14. State the specific purposes for which the entire net proceeds are to be devoted and in what manner.
C /I ~.cTY) f?/}-'T ;2..TOTL C!. J )/;) 1/?,-,1) A-rrrr7C-/$S;,
wear (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. Alr the answers'
contained in this application are a material part hereof.
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 Game' of
Chance Licensing Law and the Rules and Regulations of the Board.
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 & Wagerin
Board and local licensing ordinances or laws, will be present at all times, in charge and primarily responsible for the conduct of games.
. j
That the undersigned will be responsible for the holding, operation and conduct of all games of chance in accordance with the terms of the liceqse,
the provisions of the Games of Chance Licensing Law, the Rules and Regulations of the N.Y.S. Racing & Wagering Board and with the provis~ons
of local licensing ordinances or laws. i
I
That the undersigned has read and is familiar with the provisions of the Games of Chance Licensing Law as amended, the Rules. and Regulatio~s
of the N.Y.S. Racing & Wagering Board, and the local licensing ordinances or laws.
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.
illJ/0iJ/~
ate
~A'~/S (!. ~~
Print Name
OF NEW YORK }
1..., ~
COUNTY OF \. . 5
CITYfroWNIVILLAGE OF~I~~tncll ~ ss
~~J S c:..5 crv\.Q,4- being duly sworn deposes and says that (s)he is the person above named,
at (s)he has read the foregoing statement and the answer therein noted, and that such answers are true and that (s)he has personally
fixed his (her) signature to this affidavit.
STATE
~. j. /'
Norn to before me this t 4 - day oJ~, 20 ~
Signed ~
Commissioner of Deeds
Notary Public
y Commission expires S. lO
,20~
- - - - - - - - -
MARIE PILON ~ '
Notary Public. State of New York ~
NO.01PI6109533
Qualified In Dutchessj:ounty^ ~
My Commission Expires X. { () . Q5 ~
_ BJ.GC.2 (Rev. 4/03)
Page2of2
1111111111111111111111111\ III .J
\::
-
--,
G-C-2A
APPLICATION FOR GAMES OF CHANCE LICENSE
'lYS RACING & WAGERING BOARD
I Watervliet Ave. Ext., Suite 2
\lbany, NY 12206-1668
felephone (518) 453-8460 Fax (518) 453-8492
'Iww.racing.state.ny.us
pJ-~6-e
Name of Organization
GC- [LliJ - Gi1W - [Z[ili] - ~
NYS Identification Number
CHEDULE 1: OFFICERS AND DIRECTORS
st names. addresses and dates of birth of all officers.
organization is a corporation. or an incorporated or unincorporated association. list officers and directors.
TITLE NAME DATE OF BIRTH STREET ADDRESS CITY ZIP
ei4-~ re2);f#~ 1If.W2.+=S (I, JOi1er-1..E#1 ~I .1:L I Iv).. ~4r~J ~ I 517~;//'/1e.. I 1~-tJ-
L~,.J. " rl .r'q'~ F. :jJ.e.61',*<1~/ "'- / n'l $'.) hH<z-~/A/ I 8.<4N// I pr<y
; 6 1/ J/;,?J~,=/) s1sft./r51t2-I-E.!:::.1 !!LI $"V 1.>7 M'/I/~ k~/Z-I nvq.-?KefAl'J /:U i3
t?; l.a11i4-,Aif A1<<1~( f)C/2../{../t/( A. ,IJJ/JtA----ft1 ~I :&-1 /7 ~/.:4!r Uilcr-I ~/~.4rf . I /;;..r1y'
7i:.ekJ tin. ~ I ~;cAMd j)i5~,,/.ut:;..,J--iLI of 1 LL I /0 /!lJ12shHl 1);'Z I I lJu;j~~Jd:J /J-.6~ /
JeU-/i;fl"il /J. o~e<.T 1o/..;Jt4f'?'/JAI;~ -11:-1 z...r 1 t/~ I /0 jI~~lt..iJ.::lA..4;V I ttI~.P;"1~~~ /J-f9#
('IJ.4-fJM-jAf I .m.~/< It FOx... 1--2-1 LL-I 05'7 17# T1Jt:7L M I ~ :r./~ . 1: . /0"'..3
"1',,,,,- ~,J 110.<011"*"/,, ~c.7iii- I~/ -L../ '1'03 13'-fi ~.t ~'j~<<fl"/~ I /1-' 03
eS&u;:n? '.f~/.('ff ..fBFXA-1Y1JCJ I~I -E-I 'f~-I ('7 ~;;'Alq l..4I1C:F I ~/;:C;f I /;J-JZ'I
1/LC:;/l- I :J~1J1~/i,pG. IfLfMv-J I~I :;.1 1 3f If.) ~crl}~~ 1&1 I AJ1t>/~Bn-tJt /:2SyoJ
~Jfi::--- II4uL tI, Wf3=Jz- JJL 1-1-1 ZD 1 6~~1/3,/ #)/AlEJ.P~ ~J I C:~~yev/~ /~-.;() ,
Attach additional sheet if necessary.
0LJ/~/0a
Date
:CHEDULE 2: MEMBERS IN CHARGE OF GAMES
(MUST LIST AT LEAST FOUR MEMBERS OF APPLICANT ORGANIZATION)
DATE YEARS OF
NAME OF BIRTH :MEMBERSHIP STREET ADDRESS
1_/_/_1 I. .
#Ji)I2~"lJ alLY;; 111 -1L 1 -#1-1 2- I J 0 i ~ t ~il
::J/1d..7Ud' ;'',,/t? J?i5); -1:.. 1 .:!:.:L. 1 3 S' 1"2- I fjj t3~o fA e4-~ /<.1
eith/HI.J J}z~t.I:Z~ -1L /0 ~/ 1 ~I ~o I /1 !J'l4+1..i~4-// f)~
H/JfLt7-./~' r. fltrl?j I.J!L 1 -3L 1 ~I / ~- I /1))... 6~"r1;eu 14/
I 1 1 1 I
/=/=/=1 I
I 1 1 I I
1=1=1-' I
CITY
ZIP
;CHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF 2 AUXILIARIES/ AFFll..IA TES. EACH AUXILlAR Y/ AFFILIATE LISTED MUST HAVE ITS OWN ID NUMBER.)
NAME OF AUXILIAR Y/ AFFll.,IA TE
GAMES OF CHANCE ill NUMBER
BJ.GC.2A (Rev. 4/03)
-
Page 1 of2
11111111111111111111111111111 -1
I 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 organization or affiliate for at least 1 year. '
YEARS OF
MEMBER NAME . DATE OF BlRTH 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
I 1 1 1_1
1=1=1= I _ I
I 1 1 I I
'-1-1-\-1
1-1-1-1-'
1-1-1-\-1
1=1=1= 1 = I
I 1 1 I I
1=1=1= I = I
1_1_1_1_1
1_1_1_1_1-
I 1 1 I I
1=1=1= I = I
1_1_1_1_1
1_1_1_1_1
1_1_1_1 _I
1_1_1_1_1
I 1 1 I_I
1=1=1_1_1
1_1_1_1_1
1_1_1_1 _I
1_1_1_1 _I
1_1_1_1_1
1_1_1_1_1
1_1_1_'_1
1_1_1_1_1
1_1_1_1_1
1_1_1_1_1
CITY
i
!
iZIP
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11111111111111111111111111I11 ..J
. 13.l-GC-2A (Rev. 4/03)
Attach additional sheet if necessary.
Page 2 of 2
I
, 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.mcing.state.ny.us
APPLICATION FOR GAMES OF CHANCE LICENSE
N arne of Organization
GC- OJ - UTI - OJ] - ITIIIJ
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 ZlP
~"~1JZ.-'C" I /df;.-ic:{.i P1M:M.7Zf.11/ /I. / 'III,..: ;2c/xf7,.7I w I -= />d7'
I <-us rrd I d--ej7.~-" J"i7;&12.d-/ I.-LI.l:-I .!a.1~/v JJ#M1J 1 ~_ ~~ ';).4,63
1t'-'1t/~ I Lott.l.1 lJ-u7dL.07T/ I~I Jd..1 ~I )'l-f 4b/'f:rc'J ~~rHjIj; I /Z-~~
-r,2.tfs~ 1/4'1')Z.laIL OIt!.4A/PG// 1-'k.1..:L!!.1 E 71 JI~ i!1puI' 1/;/'-1 !WC,f 1 /),-5~ If
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I 1_/_1_1 I I
I 1_/_1_1 I 1
I 1_/_1_1 I I
I /_/_1_1 1 I
I 1_/_1_1 I I
Attach additional sheet if necessary.
OJIOJICD
Date
NAME
MEMBERS IN CHARGE OF GAMES
(MUST LIST AT LEAST FOUR MEMBERS OF APPUCANT ORGANIZATION)
DATE YEARS OF
. OF BIRTH MEMBERSHIP STREET ADDRESS
1_/_1_1 1
1_/_1_1 1
1_/_1_1 I
I_/~/_I I
1_/_1_1 1
1_/_1_1 I
1_/_1_1 I
1_/_1_1 I
1_/_1_1 1
CITY
ZlP
SCHEDULE 2:
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/ AFFll.lA TE
GAMES OF CHANCE ill NUMBER
11111111111111111111111111111 .J
L BJ-GC-2A (Rev. 4/03)
Page 1 of2
~
I
,
I
r SCHEDULE 4: ASSISTANTS TO MEMBERS IN CHARGE OF GAMES 'I j'
List all members of applicant organization and members of authorized affiliates and auxiliary who will assist with games. Each person listed mustl1e a
member of applicant or~anization or affiliate for at least 1 year. '
YEARS OF
MEMBER NAME . DATE OF BIRTH MEMBERSHIP STREET ADDRESS
'_1_1_' _I
'_1_1_' _I
1_1_1_1_1
I 1 1 I_I
1-1-1- I _ I
---I
1_1_1- _I
, 1 1 I_I
1-1-1-1_'
'-1-1-1 _ I
1=1=1= I _ I
I 1 1 I_I
'-1-1-'_1
'=1=1= I _ I
I 1 1 I_I
'-1-1- 1_ ,
'=1=1= I _ ,
, 1 1 I_I
1=1=1= I _ ,
1_1_1_1_1
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1 1 _I
=1=1= _,
1 1 ,
=1=1= =,
_1_/- _I
1/1
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=1=/= =,
1/1
=1=/= = I
_1_/- _,
_1_/- _I
L BJ-GC-2A (Rev. 4/03)
Attach additional sheet if necessary.
Page 2 of2
CITY ZlP
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:-2B APPLICATION FOR GAMES OF
'S RACING & WAGERING BOARD CHANCE LICENSE
{atervliet Ave. Ext., Suite 2
lany, NY 12206-1668
ephone (518) 453-8460 Fax (518) 453-8492
w.racing,state.ny.us
GC- [ili] - [iliEJ - [iliJJ - ~
NYS Identification Number
~HEDULE 5
[]J/[illl/~
Date
/ I am / pm -
-"---' , , , I. . ,
/ [ ,am / pm -
~ , , , ,. .
I I am / pm -
~ , , , . . , ,
I I am / pm -
~ . , . I. , ,
I I am / pm -
~ . . , , . ,
I I am / pm -
~ , , , I. I ,
/ I ,am / pm -
~ . , , .
, .
/ I ,am /pm -
~ , , , .. .
/ I am / pm -
,
~ , , . , , ,
J I am / pm -
-"---' , , , ,. . , ,
J I am / pm -
'""--' , , , t. . , ,
J I ,am /pm -
'""--' . . . .. . ,
\..FFLES
DATE TIME
PRIZES (Cash or Fair Market
Value of Merchandise)
!$, , . . , ,', .
1$,
!$,
!$.
!$,
-,-"J
-'-" / ,
-,-"I
~J.
-,-"J
.!, ,'. ,am/pm - ,', ,am/pm
,!, ,'. ,am/pm - ,', ,am/pm
I am/pm - am/pm
, I . ,.,. II. I
I am/pm - am/pm
, 1 . . . ., . . . .
I am/pm - am/pm
, I . ,I I' II.
~HEDULE 6 i I d': EXPENSES
st items of expe'1J e to be incurred, and the names and addresses of persons to be paid.
:EM OF EXPENSE VENDOR NAME STREET ADDRESS CITY
J
, / .
, / .
.J
./
I. .
. . ,
i.'
II .
STATE
ZIP .
BJ-GC-2B (Rev, 4/03)
Page 1 of2
11111111111111111111111111111 --1
I
lot
I
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 5. 1
Note for Ve1!as Ni1!hts and Bazaars only: The total amount of prizes during anyone license period sh~l not
aggregate more than $400 for each single type of game of chance when five types of games of chance arel to be
conducted during anyone license period. The total amount of prizes during anyone license period shall ~ot
aggregate more than $500 for each single type of games of chance when less than five single types of g~es of
chance are to be conducted during anyone license period. !
i
UST THE MAXIMUM AMOUNT OF P~S
TO BE AWARDED FOR EACH TYP;.~r
GAME OF CHANCE (GAME BANK)
at $
at $
at $
LIST NAME OF EACH TYPE OF
GAME OF CHANCE
(Limit: 5 Garnes)
at $
at $
For Merchandise Wheels, Bell Jars and Raffles, please complete the appropriate spaces below.
MERCHANDISE WHEELS:
INDICATE NUMBER OF
MERCHANDISE WHEELS
(NO LIMlT)
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 APPUCA TION
IS FOR A BELL JAR
UCENSE
YES~ NO 0
THE TOTAL AMOUNT OF PAYOUT~
FOR EACH BELL JAR DEAL SHALL NO]
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, UST RAFFLE DATES, TIME(S)
OF DRA WING(S) AND PRIZES IN
SCHEDULE 5
BJ.GC.2B (Rev. 4/03)
Page 2 of2
THE TOTAL AMOUNT OF PRIZES FOR
ALL THE RAFFLES CONDUCTED DUR-i
ING THIS CALENDAR YEAR SHAL4
NOT EXCEED $100,000. NO SINGL~
PRIZE SHALL EXCEED $50,000!
EXCEPT THAT A SINGLE PRIZE OFI
$100,000 MAY BE AWARDED IF SO!
INDICATED IN SCHEDULE 5
11111111111111111111111111111 --.J
r
GC-4
NYS RACING & WAGERING BOARD
1 Waterv1iet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
-,
FINDINGS AND
DETERMINATION
FOR GAMES OF CHANCE
LICENSE
GC - rn - GIiliJ - GliW - ~
N.Y.S. Identification Number
Town of Wappinger
Name of Municipality
Dutchess
1195 Route 376 Wa in ers Falls New York 12590
Address
After investigation, and a hearing if required under Sec. 192.oYhe General Municipal Law, the following findings and determinations
have been made: /
I. All the membe~-in-clwge designate(E, the appli<;>ti~ to cgnduc b ~ f ch ce are. of good moral Me", 0 No
character and have never been convicted of a 'm V' r
Signature of Person Conducting Investigation
She~\{=-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!lfe 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)
tV' / fI-
Nj If
~Yes DNo
I\ZI Yes DNo
~Yes DNa
liS Yes DNa
~Yes DNo
1St Yes DNa
IE. Yes DNa
DYes DNo
DYes DNo
TO BE COMPLETED BY MUNICIPAL CLERK: .
/
As a result of the findings and determinations stated above, license is GRANTED giicense is DE
~ Signature of
Filing date of Application / / ~ 1.5 Authorized Officer I
I ~iCiPal
Date -j,f;<~ S Title.
ONE C Y OF 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 (R". 4J03l I~ 111110 1IIIImmllll ~II .-J
I
GC.S
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
LICENSE TO CONDUCT
GAMES OF CHANCE
. PLEASE CHECK
GAMES OF CHANCE 0
BELL JAR ~
RAFFLE 0
GC - m - ~- [ili]2J - WiliJtlJ
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: 1195 Route 376 City: WappinJ!ers Falls
Entire net proceeds to be devoted to the following specific lawful purpose(s):
Charity, Patriotic, Youth Activities. Educational
Names of Members in Charge
Andrew Corti
Zip Code: 12590
Jacqueline Alfano
Richard Desruissenu
Harris C. Jones
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 Fan 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.
TOWN OF WAPPINGER
(Name of Municipality)
January 25, 2005
(Date)
GAMES SHALL BE PLAYED IN ACCORDANCE WITH
STATE LAWS AND RULES AND LOCAL ORDINANCES OR
LAWS.
Issued by
)
~
utho Officer)
1 11111111111111\ 11\ 11111 -1
L BJ.GC-5 (Rev. 4/03)
..
1476
BPOELKS NO. 2609
BELL JAR ACCOUNT
P.O. BOX 47
GC 13-219-602-02013
WAPPINGER FALLS, NY 12590
DATE
m~:r- 50;:S35S66
I ~ ),tJZ}
PAY _____ /. ) c".
TO THE ,/"j' _ ~ )
OR~~~"7, ~~
'v~~~~ ?~ ~ ~.,-v '-
BANKOF
YONEWRl( 423 South Road
Poupteepsic, NY 12601
FOR~~~
II-OO.~ 71;11- 1:02.11023521:
DOLLARS mE:~=
~/
. . _ ?../2--------~
II- 0 2 7 B 0 3 11 7 .11-
TOWN CLERK
TOWN OF WAPPINGER
20 MIDDLEBUSH ROAD
WAPPINGERS ~LLS. ~EW YORK 12590
RECEIVED FROM ftJ. ~ .# ,? &~ 1
1''' /~" __
08148
DATE 9.e,e..~ :It. ~~CJS
f' .
$1 &15 EJ
DOLLARS
FOR
BALANCE DUE
~ ~<}OO
BVoI. ~
TOWN OF WAPPINGER
TOWN CLERK
GLORIA J. MORSE
SUPERVISOR
JOSEPH RUGGIERO
TOWN COUNCIL
VINCENT BETTINA
MAUREEN McCARTHY
JOSEPH P. PAOLONI
ROBERT L. VALDATI
TOWN CLERK'S OFFICE
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS, NY 12590-0324
(845) 297-5771
FAX: (845) 298-1478
November 26, 200i-
Adrian Anderson, Sheriff
150 North Hamilton Street
Poughkeepsie, N Y 12601
Dear Sheriff Anderson:
Enclosed, please find a copy of the "members in charge" of the Wappinger Elks
#2609, Route 376, Town of Wappinger, who will be selling BELL JAR Tickets on
their premises throughout the year 2005.
I would appreciate your review of the application and then complete the "Findings
and Determination" form attached.
Thank you for your attention to this request and your prompt reply.
Yours truly,
Gloria J. Mors
Town Clerk
Town of Wappinger
smk
--,
FINDINGS AND
DETERMlNA TION
FOR GAMES OF CHANCE
LICENSE
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
GC - W - [ililiJ - GIili1- GIiliill
N.Y.s.ldentification Number
Town of Wappinger
Name of Municipality
Dutchess
AftN investigatinn, and a hearing if requi",j unde< Soc. 192 nf the Genern1 Municipal Law, the fnllnwing finding' and detenninations
have been made:
1. All the mem_-in-chorge d"ignated in the applicatinn to cnndnct games nf chance are.nf gnod moral 0 y" 0 No
character and have never been convicted of a crime.
1195 Route 376 Wa in ers Falls New York 12590
Address
Signature of Person Conducting Investigation
Title
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 !ll"e 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 fmdings: (Specify)
,11ft
II/ft
M' Yes DNo
IKI Yes DNo
00 Yes DNo
1tJ' Yes DNa
~Yes DNa
1St Yes DNa
[g Yes DNo
DYes DNo
DYes DNa
~
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
(Municipal Licensing Authority)
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 (R<<. 41031 11111111111 \1m 1m II \\I m ~
Date
~.;:
-,
APPLICATION FOR GAMES OF CHANCE LICENSE
.C-2A
is RACING & WAGERING BOARD
Watervliet Ave. Ext., Suite 2
bany, NY 12206-1668
:lephone (518) 453-8460 Fax (518) 453-8492
NW .racing.state.ny .us
iJJ.4 P.1- IlJ 6- r::
Name of Organization
GC- [LliJ - ~ - [tlli] - ~
NYS Identification Number
:::HEDULE 1: OFFICERS AND DIRECTORS
t names, addresses and dates of birth of all officers.
'rganization is a corporation, or an incorporated or unincorporated association, list officers and directors.
TITLE NAIvIE DATE OF BlRTH STREET ADDRESS CITY ZIP
,ei4~ r..t<P l<tk II-=s f, :btlff I ~ / ~ / J~iJ Iv,l. .3<. tk....i /l./ I 5~?M..r:/1e.. I / >-d:t-
~/,J. " kl ~t;(/hJ li :P:: 6/~ ...fl; / ~ / LZ I 5.J {'J V "-"- -M /;./ I f!:(hl{ 1/ . I pS-l'l
~,' .' ~ s. JfJt Ir.fft2-J~J::. / .!L / 5X' ,)f M 1/ ~ 7h</2-1 Ii. f IjK ~ J /U i3
; Lat.'I>>! ~t~ fCflA.i'l( II, -i!.1t},-IP-I .!..LI !IE- /1 ;;..,/~ tHkl /fr1v1"~f . I /:<.,-1'/
7&~"s o~.a.-I ~C_~ f)t3Rviff~.--ILI or 1 2L L' )t4/2sM/ 1};t, I ;;~vo/,/~l 1;>."/
f(U" 11/1' 'II ;< 0 ~e<.1 /1'1. t:1t.~ ,,!IN, mt..1J"j,..r 1 i/z. I /' ~/ "-/I ,#..;p.v I j..4 '---" /"1"it ~ L HY,7
C 6"1" j,,;.. N I /11_1< ffi f'O x. I---L 1 .!L- 1 57 I -;,f maL 4L kz1h""""1 J!;=1 /if.l3
7:1',:J>- ~,J I ~""'I1I-,""-i,, ~C'M- I tr / 7 / '/.3 3'-&7,,, Je.l 11I.,U-eeK/<:: I / >.t '3
6#,';fl? IS.w/v.YaEX"""(' I ;,,1 p 1 of"- .7 fj,.~'N7 <,mtF I ~/ivj I 1m';
-(/L-c;Z- I ::/1/61,";1,<- IldM'l< I~I ..7 1 :3i If) z:,..,rhc.<-' M I ;JAf'/~-~ /2.5y~
1f;,,;;f2~ I (;",L- I), ~ iff: l---LI7:!!-1 6/"1/3'1: Il~'-,u I ~~lev.,A /%'10
Attach additional sheet if necessary.
0L]/[lli]/02t
Date
CHEDULE 2: MEMBERS IN CHARGE OF GAMES
(MUST LIST AT LEAST FOUR MEMBERS OF APPLICANT ORGANIZATION)
DATE YEARS OF
NAME OF BlRTH MEMBERSHIP STREET ADDRESS
1_1_1_1 \. .
~ty.J (k.r, 1_1.J-LL 1 -111-1 L Ii. i ~ /I /4r.,iL
~/lt-1,u:Jt' t?t5J~1 1::2-1 39" 1:2- I qJ {brhe,... Ii..!
~i(;Mfl.J 'j)&;S,<",;Z~ --LL 1 ~ ~/ 1 ~I J.o I /1 !J1,Mu~4-I/ [l~
ij~/!.' r. fltf'~ I ~I -y-I LLl I>' I /~;.. 6e"r1;eU IZ/
1_1_1_' I
1_1_1_1 I
1_1_1_1 I
1_1_1_1 I
CITY
ZIP
:CHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF2 AUXILIARIES/AFFILIATES. EACH AUXILIARY/AFFILIATE LISTED MUST HAVE ITS OWN ID NUMBER.)
NAME OF AUXILIARY/ AFFll1A TE
GAMES OF CHANCE ID NUMBER
1111\11 \ 11111111\ II III 1\ III II ~
BJ-GC,2A (Rev. 4/03)
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