Knights of Columbus 1646
r
GC-2
-,
NYS RACING & WAGERING BOARD
I Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
APPLICATION FOR:
PLEASE CHECK
GAMES OF CHANCE 0
~r~r~;azaars, CarniValS)(
RAFFLE 0
(only raffles wI over $30,000 net profits in calendar year)
FOR OFFICE
USE ONLY
$1 25 . 00
Fees Received
[ili] / EGJ / [il6J
Date
INSTRUCTIONS: PLEASE FILE THREE SIGNED COPIES WITH MUNICIPALITY
GC - CITIJ - [TIJ]5]- ~- ~
N.Y.S. Identification Number
IT IS A MISDEMEANOR TO MAKE ANY FALSE STATEMENTS IN THIS APPLICATION
'\OW\~ oF' L,lJA10{Ji N~ Uu.\C..l-\--e.s.S
Name of Municipality County
1.
I 10 lf b
2. Address 2 ~ j 10 '1
3. Has applicant ever been denied a games of chance license? 0 Yes JrNo If "yes", why? (Attach extra sheet if necessary)
4. Check type of organization and. if applicable. give the State and date of incorporation.
Corporation 0
State incorporated
Incorporated Association 0
Unincorporated Association 0
State incorporated
Dale[D/[D/[D
Date[D/[D/[D
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 ~o If "yes", what is the trade name?
PARTB. LOCATIONOFGAMES
7. Address where games. bell jar, or raffle drawing(s) are to be conducted. 2. Z:...C\~-3""\ MA i v-..i ST, Lu Pf;J1--
8. Name and address of authorized games of
chance lessor renting to applicant.
~/A
9. Does the applicant own the premises? )z( Yes 0 No If "yes". how long?
10. Capacity for public assembly of premises presently owned or occupied.
;.
39
~iq
11. Have premises been regularly used? ~ Yes 0 No If "yes". how long?
Are games of chance being played now on these premises or has it ever been? 0 Yes 0 No If "yes", give full details.
12. Are the premises or any part thereof
where games of chance are to be played ~ Yes 0 No
licensed by the State Liquor Authority?
If "yes", state the type of license and number.
Lk Set 2Y3
13. Has such license ever been 0 Y
revoked or suspended? es
~o
If "yes", why? (Explain on a separate sheet, if necessary, and attach.)
L BJ-GC-2 (Rev. 4/03)
Page I of2
111111111111 ..J
r
GC-2A
f<
-,
NYS RACING & WAGERING BOARD
I Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518)453-8460 Fax (518)453-8492
www.racing.state.ny.us
APPLICATION FOR GAMES OF CHANCE LICENSE
GC- UEJ - [iliK] - ~ - ~
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 NMyIf DATE OF BIRTII STREET ADDRESS CITY ZIP
() fl.' ~l>J t<'1V~'i ~~ B('\A(.~ It't'$~,-.30 13-1 () V /..5-' I S"-I-f....M I,~ \)R. I wc-ff ES.ll-\! 7.2SQ,)
OQP G.-,-"..{ '<""'~'t: JD\""~ (" ~-e+,.."e 1..2-1 :{q I ~I '-e{.;~"'e+~ Te (r 1 \~"-'rf (7l11( I I"2-FCZO
C h C...H.e Il 0 A.. j(~ Il_ \{ 11",-,..> N~+r-tJ....iLI ~/ )"5 '\~/D ffJ "J I),.. "r ~ A I r ,l~lAl'!j. c~ I ( 1- (.0 3
.A e L or-44> r I 0,,-,,(;.. Bro \..U,.,) 1-.::1..1 2-1 b 8' , ;Z 5 ~N; ~ A ve I O~ v ~"'.> ,I I 'L"-O j
JrH S \.\..(t~ r? IJ'\ ,'(. K DCv ll'-~ I..::LI 3-1 ~ I S-<.t ~. ()l.pslot'r A 11<.1 \ /\.hr r l~d(11 2... j-qn
F:lrJc,~ ~ 'A-L5"Lf~JI ~IL (flv..~leNbrv.,,-1t.-.:LI j-) I 32. I I 0 ~k-<r''1'.....<>A ~I c G=G: l6 II LSCi 0
A/;lvou.d-e. l_rJ, ke ILe..B y I~I .J.:l.....I 3.11~, :HI II i ~ lee-/" I ({~ ."")' I i 2- ~o >~
\AAf'u\e0 , {Y)'^y DAD 1..J2:..1 ~/ 4d.1 L ,,""" I_~'W I L' ~1Q~> II) ~ rei
Tr'-'-s.'t-~e I ,~e'-C-'- C?Mldr,1o.l 1..L2-./oLlfoO 1 .{' ~~r II c: Il2-S'1Z'l
T ~ ",,:t- e lilt-:-. · LX' , r '" I...:J..../ "1..0 / .fQ.ll b a,. S<<r~ f( J. 11'2 ofe I:::" I I >....><1 0
'Trl.< d-<-e 1 (Y) , \-< ~ I-<e II X l..l( 11-. I ~Iq I - l-L 1\ I'~ T-ert: I~ I I L"-c ~
ttach additiOnal sheet If necessary. p (!) v..~ 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 CITY ZIP
-J~I\\.." 5 eXbl'-'NcnJ -1.L I L) 1.5- \ 1 :L~ II - I-L'S,lt ~ i' IGO&- 1> f (=ql[-..s. I (1- S'LV
Jo~,..:> C:'ort(l,..-I...:LI '2,) I S3 1 /8 II~ ~'f<.A-~"", OR. 1 Wf>f 5-'(s;/ I t L)'tO
J 0 k ~ ~ i M.... "'~ 1 J.L I.J..L. /.:S:.!:LI ?..1D I 5 I De( f3" ~ () IJ l ,)~ I~; q~ -l. I,l.-.r~ D
fY'I~x D~ 0 I ~I .:3..LI J2..1~I-6J)lulU i Lo N .' I J1~_ c~__, <" I 12) it')
'_1_1_1 I I I' I
1_1_/_1 I I I
1_1_1_1 1 I I
'_1_1_1 1 I I
1_1_1_1 1 I I
rn/~/~
Date
SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF 2 AUXD..lARIESlAFFILIATES. EACH AUX8.IARY/AFFUATE LISTED MUST HAVE ITS OWN ID NUMBER.)
NAME OF AUXlLIARYIAFFnlA TE
GAMES OF CHANCE ID NUMBER
L BJ-GC-2A (Rev. 4103)
Page 1 of 2
~IIIIIIIIIII ..J
r SCHEDULE 7 TYPES OF GAMES "I
Ust all of the single types of games to be conducted at all license periods enumerated in Schedule 5.
Note for Ve28S Ni2bts and Bazaars only: The total amount of prizes during anyone license period shall not
aggregate more than $400 for each single type of game of chance when five types of games of chance are to be
conducted during anyone license period. The total amount of prizes during anyone license period shall not
aggregate more than $500 for each single type of games of chance when less than five single types of games of
chance are to be conducted during anyone license period.
UST NAME OF EACH TYPE OF
GAME OF CHANCE
(limit: 5 Games)
UST THE MAXIMUM AMOUNT OF PRIZES
TO BE AWARDED FOR EACH TYPE OF
GAME OF CHANCE (GAME BANK)
at $
at $
at $
at $
at $
For Merchandise Wheels, Bell Jars and Raffles, please complete the appropriate spaces below.
MERCHANDISE WHEELS:
INDICATE NUMBER OF
MERCHANDISE WHEELS
(NO UMlT)
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 APPUCATION
IS FOR A BELL JAR
UCENSE
YES)( NO 0
THE TOTAL AMOUNT OF PAYOUTS
FOR EACH BELL JAR DEAL SHALL NOT
EXCEED $3,000 AND NO SINGLE PRIZE
SHALL EXCEED $500
RAFFLES:
INDICATE IF THIS APPUCATION
IS FOR A RAFFLE
UCENSE
YESO NO 0
IF YES, LIST RAFFLE DATES, TIME(S)
OF DRA WING(S) AND PRIZES IN
SCHEDULE 5
THE TOTAL AMOUNT OF PRIZES FOR
ALL THE RAFFLES CONDUCTED DUR-
ING THIS CALENDAR YEAR SHALL
NOT EXCEED $100,000. NO SINGLE
PRIZE SHALL EXCEED $50,000
EXCEPT THAT A SINGLE PRIZE OF
$100,000 MAY BE AWARDED IF SO
INDICAlED IN SCHEDULE 5
L BJ-GC.28 (Rev. 4103)
Page 2 of2
111111111111 .J
I
I
GC-4
NYS RACING & WAGERING BOARD
1 Waterv]iet Ave. Ext., Suite 2
Albany, NY 12206-]668
Telephone (518) 453-8460 Fax (5] 8) 453-8492
www.racing.state.ny.us
I
FINDINGS AND
DETERMINA TION
FOR GAMES OF CHANCE
LICENSE
GC-GG]- [2EG - ~- ~
N.Y.S. Identification Number Municipal License Number
Town of Wappinger
Name of Municipality
Wappingers Falls, New York 12590
er I Municipal Law, the following findings and detenninations
g(s D No
After investigation, and a hearing if required under Sec.
have been made:
I. All the members-in-charge designated in the
character and have never been convicted 0
Signature of Person Conducting Investigatio
Title
Sheriff
--.-,..
2. Applicant is a qualified authorized organiz
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 Garnes
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 Lo be paid to an authorized games of chance lessor is reasonable.
10. Other findings: (Specify)
n/a
DYes DNa
DYes DNa
DYes DNa
DYes DNa
DYes DNa
DYes DNa
DYes DNa
DYes DNa
DYes DNa
~
JAt..
~\;j6
TO BE COMPLETED BY MUNICIPAL CLERK: /
As a result of the findings and determinations stated above, license is GRANTED~; license is DE~O. _".
Signature of
Filing date of Application 12/9/2005 Authorized Officer
Date
1/2/2006
Title
Town Clerk
ONE COPY OF THIS FORM TOGETHER WITH ONE COPY OF FORM GC.2, 2A, 2B MUST BE RECEIVED BY THE
N.Y.S. RACING AND WAGERING BOARD FIVE DAYS PRIOR TO THE FIRST AUTHORIZED LICENSE PERIOD.
L BJ.GC.4 (Rev. 4/03)
111111111111111111111111I1111 .J
I
GC-4
NYS RACING & WAGERING BOARD
1 Waterv1iet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (51 8) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
-,
FINDINGS AND
DETERMINA TION
FOR GAMES OF CHANCE
LICENSE
GC-GI2J-~-~-~
N. Y.S. Identification Number
Town of Wappinger
Name of Municipality
Street, Wappingers Falls, New York 12590
Municipal Law, the following findings and determinations
~s D No
After investigation, and a hearing if required under Sec.
have been made:
1. All the members-in-charge designated in the
character and have never been convicted 0
Signature of Person Conducting Investigatio
Sheriff
Title
2. Applicant is a qualified authorized organiz 'on 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 wiIl 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)
n/a
DYes DNa
DYes DNa
DYes DNa
DYes DNa
DYes DNa
DYes DNa
DYes DNa
DYes DNa
DYes DNa
TO BE COMPLETED BY MUNICIPAL CLERK:
As a result of the findings and determinations stated above, license is GRANTED D; license is DE~. -"0';
Signature of
Fi ling date of Application 12/9/2005 Authorized Officer
.~
JAr 'j" '.'f'lP6
\. ,- - {,=\"U -
Date
1/2/2006
Town Clerk
Title
ONE COPY OF THIS FORM TOGETHER WITH ONE COPY OF FORM GC-2, 2A, 2B MUST BE RECEIVED BY THE
N.Y.S. RACING AND WAGERING BOARD FIVE DAYS PRIOR TO THE FIRST AUTHORIZED LICENSE PERIOD.
L BJ-GC.4 (Rev. 4/03)
11111111111111111111111111111 .-J
I
GC-5
--,
NYS RACING & WAGERING BOARD
1 Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
LICENSE TO CONDUCT
GAMES OF CHANCE
PLEASE CHECK
GAMES OF CHANCE r::y
BELL JAR [j"
RAFFLE 0
GC - GliJ - lliEJ- GJill- [ililiIiliJ
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
Entire net proceeds to be devoted to the following specific lawful purpose(s):
Charity, Patriotic, Youth Activities, Educational
Names of Members in Charge
James O'Connor
Falls
Zip Code: 12590
Max Dao
LICENSE PERIOD
DATE
YEAR 2006
DAY OF WEEK
.;/
(; ~ J.(j
-PD"tA \Of;
f\ ,1/1
'PE(S) OF GAMES
John Gorman
John Simons
RAFFLE DRAWING
DATE
DRAWING TIME
DRAWING LOCATION
AMOUNT OF RAFFLE PRIZES (Cas~ or Merchandise Prizes
at Falf 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)
ignature of Authorized Officer)
11111111111111111111111\ 11111 --1
January 13, 2006
(Date)
L BJ-GC-S (Rev. 4/03)
"
TOWN OF WAPPINGER
TOWN CLERK
CHRIS MASTERSON
SUPERVISOR
JOSEPH RUGGIERO
TOWN CLERK'S OFFICE
20 MIDDlEBUSH ROAD
WAPPINGERS FAllS, NY 12590
(845) 297-5771
FAX: (845) 298-1478
TOWN COUNCIL
VINCENT BETTINA
MAUREEN McCARTHY
JOSEPH P. PAOlONI
ROBERT L. VAlDATI
J an uary 4, 2006
Adrian Anderson, Sheriff
150 North Hamilton Street
Poughkeepsie, New York 12601'
Dear Sheriff Anderson:
Enclosed, please find a copy of the "Members in Charge" of Knights of Columbus,
#1646, 2 East Main Street, Wappingers Falls, who will be selling BELL JAR tickets
on their premises throughout the year 2006.
I would appreciate your review of the application and then would you please
complete the "Findings and Determination" form attached.
Thank you for your attention to this request and your prompt reply.
Y JfJs truly,
r~'
John C. Masterson
Town Clerk
Town of Wappinger
r
I
I swear (or affirm):
1. That ALL the attached Schedules are a material part hereof and are incorporated herein as if set out in full in the application. All the
answers contained in this application are a material part hereof.
2. That the entire net proceeds of all games of chance shall be devoted exclusively to one or more of the "lawful purposes" as defined
in the Games of Chance Ucensing 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 Ucensing Law, the Rules and Regulations of the
N.Y.S. Racing & Wagering Board and local licensing ordinances or laws, will be present at all times, in charge and primarily
responsible for the conduct of games.
4. That the undersigned will be responsible for the holding, operation and conduct of all games of chance in accordance with the terms
of the license, the provisions of the Games of Chance Ucensing 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 Ucensing 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.
[ill] / [QI5] / [QTIj
Date
.~~
0A\N\es .~. O'CoI0~)O~
Print Name
STATE
OF NEW YORK
O~
}ss
COUNTY
CITY rrOWNNILLAGE
OF
~J;;S P: 0 CO^->NO fL being duly sworn deposes and says that ~he is the person above named,
that (s)he has read the foregoing statement and the answer therein noted, and that such answers are true and that ~he has personally
affixed his (her) signature to this affidavit.
this ~
20125-
Signed
\1_ , 20~
I
CQlJ4I!f_I;~A-RINALDJ
f. '. Notary Public, State of New York
r. . .No. 4962340
;'i' . qua.hfied in Ulster County
~~ommlsSlon Expires Feb. 12. ~
To be completed by Municipal Clerk:
Issued by
(Name of Municipality)
(Title of Authorized Officer)
(Signature of Authorized Officer)
(Date)
L BJ-GC-6 (Rev. 4103)
Page 2 of2
IUIIIIIIIII .J
BELL-JAR-GAMES OF CHANCE
WAPPINGERS COUNCIL K OF C 1646
f. J -.,~,-
~ .... CJO'o~ ~~.)
1'1"'_
205
1-108/280
/Jd
/~
$ I ^- S- >o-r:::J I
FOR
;,. I: 0 2 aDO ~ 0 a ~ I: 0 a 2 7 5 5 ~ 2 2 III
@
DOLLARS