Wappingers Elks Lodge
...
I
GC-5
NYS RACING & WAGERING BOARD
1 Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (5]8) 453-8460 Fax (518) 453.8492
www.racing.state.ny.us
LICENSE TO CONDUCT
GAMES OF CHANCE
PLEASE CHECK
GAMES OF CHANCE 1[1
BELL JAR 0
RAFFLE 0
GC - [ili] - Cil2liJ- ~- ~
N.Y.S. Identification Number
~'L-C 4
"t~~,~
tV(JU
6~~/C"
I
~1
l&
ust Be
played
Games
$/ 75.00 II I
Amount of Fee Paid Lessor's License Number
Address: 1195 Rt. 376 City: Wapp i ngers Fa II s
Entire net proceeds to be devoted to the following specific lawful purpose(s):
1/3 Charitable 2/3 Operations
Names of Members in Charge
Paul Bader
Zip Code: 12590
Louis Antolotti
Simon Kaufman
Lew Hakim
LICENSE PERIOD
DATE
7/07/2006
8/04/2006
9/08/2006
RAFFLE DRAWING
DATE
DAYOF-wEEK HOURS TYFE(S) OF GAMES
Friday 7:00pm - 1 : OOam Blackjack, Joker Poker, Big Six
Friday 7:00pm - 1 : OOam Blackjack, Joker Poker, Big Six
Friday 7:00pm - 1 : OOam Blackjack. Joker Poker . BiQ Six
DRAWING TIME
DRAWING LOCATION
AMOUNT OF RAFFLE PRIZES (Cas? or Merchandise Prizes
at Fair Market Value)
THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
FOR EACH TYPE OF GAME OF CHANCE
$ 500.
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)
June 13, 2006
(Date)
TOWN CLERK
(Title of Authorized Officer)
L BJ.GC.5 (Rev. 4/03)
re of Authorized Officer)
11I1111111I111I11111111111111 ~
r~tl(
SIMON KAUFMAN
ERNA KAUFMAN
9 SOUTH VIEW LANE
HOPEWELL JUNCTION, NY 12533
~ ~;!1
I!~!)
212~J
D.", ~ ).l. I ~/'j.
t!1WJ:$n ~ 1:~~"
t rID ars ill on BaCK
50.235/219
561
,<tb1j ~ ~
O'-d.,.f - 0-<41 ~, :3::
THE BANK OF NEW YORK '1
ROUTE 82 ~
HOPEWELL JUNCTI,ON' NY 12533" . ~ / )
Fo,_L~~ _ ~~ ·
I: 0 2 . 9 0 2 ~ 5 2 I : III 0 2 7 ~ . 0 ~ b 5 ~ III 2. 2 ~
i&:; CHECK GALLERY, 1995 STYLE" P03 1-800-354-354G www.checkgallery.com
PRINTED ON RECYCLED PAPER USING VEGETABLE-BASED INKS
TOWN CLERK
TOWN OF WAPPINGER
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS, NEW YORK 12590
09393
BALANCE DUE
o CASH
~ CHECK
o M.O
BY
AMOUNT OF ACCOUNT
THIS PAYMENT
..
r
GC.4
NYS RACING & WAGERING BOARD
] Watervliet Ave. Ext., Suite 2
Albany, NY ]2206-]668
Telephone (5] 8) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
I
FINDINGS AND
DETERMINA TION
FOR GAMES OF CHANCE
LICENSE
GC - ~ - [.iliEJ - 0ill- EI3JiliE]
N.Y.S. Identification Number Municipal License Number
TOWN OF WAPPINGER
Name of Municipality
1195 Rt. 376, Wappingers Falls, New York 12590
Address
After investigation, and a hearing if required under Sec. 192 ot.ttil General Municipal Law, the following findings and determinations
have been made: ' /
1. All the members-in-charge designated in the app' at" '/ u,9.t chance are of good moral [E"Yes 0 No
character and have never been convicted of a c m
Signature of Person Conducting Investigation' S he r~ ~ +
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)
AI/A
181 Yes DNo
t!5I Yes DNo
jKJ Yes DNo
gYes DNo
~Yes DNa
]KI Yes DNo
IKl Yes DNo
~Yes DNa
dYes DNa
TO BE COMPLETED BY MUNICIPAL CLERK:
As a result of the findings and determinations stated above, license is GRANTED ~cense is DENIED 0
Signature of
Filing date of Application May 30, 2006 Authorized Officer
Co ~O~
ONE COpy OF THIS FORM TOGETHER WITH ONE COpy OF FORM GC-2, 2A, 2B MUST BE RECEIVED BY THE
N.Y.S. RACING AND WAGERING BOARD FIVE DAYS PRIOR TO THE FIRST AUTHORIZED LICENSE PERIOD.
L BJ-GC4 O{ev. 4/03) 11111111111111111111111111111 --1
Date
Title
TOWN CLERK
..
TOWN OF WAPPINGER
TOWN CLERK
CHRIS MASTERSON
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
(845) 297-5771
FAX: (845) 298-1478
May 25th, 2006
Adrian Anderson, Sheriff
150 North Hamilton Street
Poughkeepsie, NY 12601
Dear Sheriff Anderson:
Enclosed, please find a copy of the members of the Wappinger Elks #2609,
Route 376, Town of Wappinger, who will be conducting Games of Chance
on July 7th, 2006, August 4th, 2006 and September 8th, 2006.
I would appreciate your review of the "Members in Charge" listed on the application.
Please complete the "Findings and Determination" form attached and return the form
to our office.
Thank you for your attention to this request and your prompt reply.
Yours truly,
QLL.1t~
~hn C. Masterson
Town Clerk
Ene.
Y'6~ - ~~~t)
SS- l \ ." \)d?h,~
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
DETERMINATION
FOR GAMES OF CHANCE
LICENSE
GC - rn - ~ - [ilili] - [ilililiE]
N.Y.S. Identification Number
TOWN OF WAPPINGER
Name of Municipality
General Municipal Law, the following findings and determinations
After investigation, and a hearing if required under Sec. 192 oUb
have been made: ') ~/
1. All the members-in-charge designated in the app . at" '
character and have never been convicted of a c m
Signature of Person Conducting Investigation.
chance are of good moral
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 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)
AI/A
[l(Yes 0 No
aYes DNo
~Yes DNo
Jl.C Yes DNo
gYes DNo
m:I Yes DNo
]Kl Yes DNo
IK1 Yes DNo
jgI Yes DNo
dYes DNo
TO BE COMPLETED BY MUNICIPAL CLERK:
As a result of the findings and determinations stated above, license is GRANTED ~cense is DENIED 0
Signature of
Filing date of Application May 30, 2006 Authorized Officer
Co ~Olc
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 ".GC" (R... 4103) mllllllllllnm~ IIIMI -'
Title
TOWN CLERK
Date
..
,
n_ ~_ _ ____~___ ...----..~. ~-'- ..-,----'<'
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GC-2A
NYS RACING & WAGERING BOARD
I Walervliet Ave, EXl.. Suile 2
Albany, NY l2206-l668
Telephone (518) 453-8460 Fax (518) 453-8492
www.meing.Slale.ny.us
APPLICATION FOR GAMES OF CHANCE LICENSE
Name of Organization
GC- [illl- [lit IqJ - ~ - [QUIOT\ IS]
NYS Identification Number .
@ill 1 ~ ;[~l,GJ
Date
SCHEDULE 1:
US! names. addresses and dales of birth of all officers.
U' orglUlIZalion is a corporation, or an incolilOllllCd or unincorpolllled association, lisl officer> and directors.
TITLE NAME I ~ TE OF BIRTH STREET ADDRESS
(S<Z1'i. tb:rrY JM() ""-w- I - I _I \
\ 1_1_1_1 I
1 1_1_1_1 1
1 1_1_1_1 \
I 1_1_1_1 1
1 1_1_1_1 \
I 1 1_1_1 1
I 1=1_1_1 1
1 1_1_1_1 I
1 1_1_1_1 I
\ I_I ~1_1 I
'.l~"
Attach additional sheet if necessary.
OFFICERS AND DIRECTORS
CITY
ZLP
~
SCHEDULE 2:
MEMffiERSINC~RGEOFGAMffiS
(MUST LIST AT LEAST FOUR MEMBERS OF APPLICANT ORGANl1.AT10Nl
DATE YEARS OF
NAME OFBIRTH MEMBERSHlP STREET ADDRESS CITY ZlP
\1t1JL 13~~~ I~I ~/~2J~I~ ~R~S R\)f~1l-\VJi\_U;l- l)-S-~O
Loe \" 1W\11 L-o:m\ ~ 1 U 1 '::22-.1 \ I I:h?-q Rofo IY~O iii ...tJ I,~PP, 'PIl-tt-. :,1 l.l- -: <1 V
:,~ f ~ il1Rf11 ~ ~ I.JJ~I2QJ :.-r 1 r; 0 Vll+ ~I.c' \-~ ~ {' ~, :r 0: I I __!7 "" :S
1--0 w _ I 1-'\ - I ~ 1 2:;])!:i5L1?;' 12::~" V71bV (;HJtvl'H~ tv.? 1+1 1 fit\-l? I \ '" ') 'r i)
1_1_1_1 Iii
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1--1 __I _\ \ \
1--1---1--1 \ I
SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF2 AUXILIARIES/AFFILIATES, EACH AUXILIARY/AFFILIATE LISTED MUST HAVE ITS OWN ID NUMBER.)
NAME OF A
GAMES OF CHANCE ID NUMBER
1111\11 \Ill' 11"\ 1\lI\\\ III \1 .J
L IlJ.GC.2A (Rev. 4/03)
Page 1 of 2
P.y'"th~ ~~
D,.Je" of , 0-<41 .. - J;:;:
THE BANK OF NEW YORK 1-
ROUTE 82 ~
:~,w~:';:~ ___ _ ~~,,4. ~ ~
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212
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t!1#;;~$l)O='~~'
,
50.235/219
561
l' ( 7
l~~r
. G":'-"K SIMON KAUFMAN
ERNA KAUFMAN
9 SOUTH VIEW LANE
i HOPEWELLJUNCTION, NY 12533
SCHECK GALLERY, 1995 STYLE # PQ3 1.800-354.3540 www_checkgallery.com
PRINTED ON RECYCLED PAPER USING VEGETABLE-BASED INKS
"
r
GC-2'
I
NYS RACING & WAGERING BOARD
I W.lervliel Ave. EXl, Suite:1
Albany, NY 12206,1668
Telephone l,~ I H) 451-8460 Fax (.~ 18) 453-8492
www.raclng.slale.ny.us
APPLICATION FOR:
PLEASE CHECK
GAMES OF CHANCEtl
BELL JAR 0
RAFFLE 0
$\ 75.4L I [ill] / 131bl / [!E]
Municipal License _N u .::2?er__.__~ee~. ~~~~~~~_u....... _....u.._.. Date
FOR OFFICE
USE ONL Y
[NSTRUCTIONS: PLEASE FILE THREE SIGNED COPIES WITH MUNICIPALITY
GC.[illJ-~-~-~
.N YS, Idenli RClltion Number
IT [S A MISDEMEANOR TO MAKE ANY FALSE STATEMENTS IN THIS APPLICATION
~~ U () 0- w A Pp I VMLK DVTC\-t\Z. s L.;:>
N",me of Municipality \ County
PART A. GENERAL'
I N<ill1<': of Or 'uniwlion
, Has JppliCarll ever been denied a games of chan<.:e license') 0 Yes JlNo If "yes", why'l (Attach extra sheet It necessary)
:I
Cllt'd Iype 01 organi1.alion and, if applicable, give the Slate fwd dale of incorporation,
C'JI'jlIJl'UIIlIll 0
I ncurpuraleJ ,.>..SSOciHlion
~
State in<.:orponlled .1Z r'1--4..'}
'{ () Q \L
_ Date [i[J / roTil / lKW
['--] / OJ / I ~
Date 1_ L.L~
U 111 ncorporalC'd Association 0
Slate incorporated
IlldJ viJual
o
Did )"LI corpomte status change since your idenlification nUJber was assigned') 0 Yes ~No
b ."\J~ ,clU cluing bU.'iines~, under a lrade name? 0 y~s 0 No If "yes", what j~ lhe trude nelme?
PART B, LOCATION OF GAMES
Addle>s whert gam~s, bell jar. or raftle drawing(s) are to be conducted, jJ q ,r:; ~ .~ 7 ~ u..: Af e. P4flJ-S \J''-{
~ :.!J1lr JnG adl1ress of authorized games of
,han~e ksso! rrllling to applicant.
\0/r:t
---------------
'i
DOrS (h<.: ctpplic:\nt own the premises')
~Ycs
o No I!' "yes", how long)
I U C3pacrl)' lor public usst:mbly of premises presently owned or occupied,
______9.__.
d-~~
" Huv<.: prelfu;e; been regularly used'?~es 0 No [1' "yes", how long? l cr i f2A-~ S
-\Ie ~arnes of L'hance being played now on these prelllises or has it ever been? ~ Yes 0 No If "yes", give full delaJ1S
'\Y0~.O').1 d-OOC;
I') ".Ie the premises or any pan thereof
....here gamcs of chance are to be played
lll'ensed by the Stale Liquor AUlhority'!
l'ft- Y es
o No
If "yt:s" , Slate lhe lype of lil:l,nSe and numtJer
~L -- ooc>"7lf- J If-;
,3 Has slich license e~er been If "yes", why? (Explain on a separate sheet. if necessary, and attach,
revoked or suspended') 0 Yes ~o
L HJ,(,C,lIKn. 4/UJ)
Page I of 1
1/11111111 11111111""1 """ .J
I'
I
)',\ In (', I'U lU'OSES OF (;:\['1-'1 ES
14 S ''': ", t:J;' ~c IHi'R'\:rtJ. to-i" '''' i" '''' 1''' >c"t I:;; l'~ '; e~' ;T;'~W:::" S;""
.--.---.----.-----------------.
I ,W,''', \"1 .lll1nlll
I'll~l i\U, Itlc wl~h;JI<:d SI:II<:liul,~, 111'\'" 111<11"1"111 pllll 111',lelll dlld :II" IJlC\IIIHlIdll:d IlelClI1 dS II s,l ,,"I oil III 11 III Iltc IIppllcHllUli, Alltl:c JI""<;"
,"'I:_IIII~d III Ihls dppllcilllU11 dl<': illlldlc:tili IJIU I IlC,II~ul.
Ttl.!1 the: ';lltill' II~I PI\)I.\::cd:; Ill' 1111 gUII\C:'i ul dllUll:l: ~l1ull bc d~l'vl~d t~x<;lusi v~l)' IllUIlt: 1)IIl\Ore ollht' "Iawllll purposes" ~, lldiJlelll1\ lnC (j;J:1\r> "
CII~J:cc l..ll"-,lI,ll1g LllW "ncl IlIe kid", dfltl RegulatioJls nr the 1:1\)<11\1.
,i Tlh'llul t'Jdl licellSe perll,\d 101 wlticlt <I li,"',I\Se. is sDuglH, IHIt; m Illun;, (11111" uCli\'\:'IIlClllbc;l~ ullder wlHJse, supclvlsilllllllC gamcs are 10 be 11(:.:,
,'fJ<;llllJ:,i ;\lIJ ,ulldu~le:d, whu is fUl1ljli~1 wlll1lht: GUlllt:~ 01 Chllll~~ Li~~116illg Uw, the I{u!t:s JIlLl KC~lIll1tIOIl' I.)l' thc N, Y ,$, l<.a~lng & Wll~p,,:g
bu""1 illld IVI.'al II<:eIlS1I1l> ulllillallC:", 1)1' lilli'S, ",ill he, PI\',I:I\I 01 itlllilll~', III c'llall:lc Illld pli:IIltIJly iC,pulISiLJk 1111 thc <;iJlIJllct of g~II\CS
-'1 j'lllIl \I\e IllIdnslgilcd willt", I'npulISilJ\,' 11'11' the 1\l\ldil\g, opcl'illi')11 Illal ~iJIlJuL'lul' ,,11 galllCS ul' dlllllec ill d(;(lll'drlll':" willi Illc IeI'll I> 01 the ",c'IS,
'.IIC pi '" I>IUII' ut lilt: liJIlI<':S U I' Cllill\"l' U<;CIlSI\ Ig L.lIW, lite I~lll~s 1111\1 Rcglillll ium 01' lilt: t';. y ,,), 1~"<;ll\g ,I.( W agcfll\g [,mild alld Yo'IIIl lIle [.11"" ISle>'"
,)[1,),'.1, Ill'CIlS:lIg LII'Lllilllllc':S 1.\1' laws
), '11"11\l1C UlllkJ'Slgil~d ltilS rcad lIml I' l'ullliliHi' Wilt] llle prilvisiulls liI'lft.; C1alll':s ,i!'CII~lilCC l.:ct:IISil:g Llw a, 1IJIICnllcu, tllc l<.ulo "1Illl<.c~d:.::,'VI,'
,>/ 11\t: N. Y:; 1<'.ICI:I:; ,\:. W.Ig,~r:llg Ihlwd, ,uld lite lo,'illllct;Il>11l1:: "i'dlllllll';\~,' III LiIYS,
!', ll:ut IIC' ,"I\II\II>>lUI\, :;ltl,}I')', "UIIlPCIl:'il\tl"il, r\:wurll or Itl~Olllp~IIS<J will bc fl.uLllt) "11)' fl<JrsulI for twllilllllul a"isullg III tile l'pCi'iltJIIS ,J,
,,'lldu,'lllIg ,\j'tlie gUIIlc'S, C,",'L'VIIO bl)"kk,~"p~1> 1)1 Ill.'l'Olllllallls i'U"I,IJI)(~','l\Jilal >cIl'il:eS il1 all H111i1l1l1lliUl ncccllill~ Iltlll rix:u b/ tiiC Ilu;rU
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liI;II", :1" li}l~lld I,ill' fUlt:g,Jiilg SIH:t:l\lCIII Ill1d llw ill1SWcl' llit:Jell\ I1Ul~d, '''Ill Lhlll ::'11..:1\ :lIlSW<.:JS M,: lI'lIt' i\lld 11\;11 QQlilS per'",)",\! \
.i1Jlwu Ilb ~ SI1';IIHl\tr~ Iu 111I~ :llllda','lI
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GC-2A
APPLICA TION FOR GAMES OF CHANCE LICENSE
NYS RACING & WAGERING BOARD
I Walervliet Ave. Ext.. Suite 2
Albany, NY 122()6.1668
Telephone (518) 453.8460 Fax (518) 453-8492 ~.-
~W[d:~ \L- \? \D\:4ITITI
Name of Organization
GC- [ill] - [RiliJ - ~ - ~ @lJ] / ~ / C%J
NYS Identification Number Date
SCHEDULE 1: OFFICERS AND DIRECTORS
u~ names, addresses and dales of binh of all officers.
U' orgarllZ.allon is a corporation. or U1 incorpOMllCd or unincorpoMlled associalion, lisl officer; and directors.
TITLE NAME I~TE OF BIRTH STREET ADDRESS
kse~ ~~W-I_I_\
\ 1_1_1--1
I \_1_1_\
\ I_I _1_\
\ I_I _/_\
\ \_/_1_\
I \_1_1_\
\, I_I _1_\
I \_1_/-\
\ \_/_/_\
I \__I___l~\
,.,...
Attach additional sheet if necessary.
MEMffiERSINCHKRGEOFGAMffiS
(MUST LIST AT LEAST FOUR MEMBERS OF APPLICANT ORGANIZATION)
DATE YEARS OF
NAME OF BIRTH MEMBERSHIP STREET ADDRESS CITY ZIP
0tv L- 13 II. CM-i< I ~ / ~ / fe.2:...J -ll-l ~ f.Ml R~'" b (<,\) ~Jl.fv\l1 ,.L1l1-. I J- 5"" ~ 0
L-OU I" iWlfh-<m11 ~ / J:32./ '::2:L1 I \ I 7-d-~ Rof., I ,,~. ~ I-,IJ l,uifPe. f.*-tt.. '71 1,)-. S- 1 D
~~i tV -'tiRr'11.~ '~_I.lk-/!2JL1 ~ I ~ So;r ~4}\.-~' t1t"~' :fer: I I t- ~ "?7 3
Lc.~ w' ) M 1...:J./,J;2/..':15..1 3 It: 11)" I'Z ~v IWr-XH ~ w Il-P f fIH..' !? i \:r-)" '1 0
\--1--1--\ \ \
\--1--1--\ I \
\--1--1--\ \ \
I_I __I --I \ \
1_1--1--1 I I
CITY
ZIP
SCHEDULE 2:
SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF2 AUXu..LARIES/AFHLlATES. EACH AUXu...lARY/AFFILLATE LISTED MUST HAVE ITS OWN ID NUMBER.)
NAME OF A
ILIA TE
GAMES OF CHANCE ID NUMBER
1111\11 \ 111I 1111\ II III II III II .J
L tlJ.GC.2A (Re.. 4/03)
Page 1 of 2
r SCHEDULE 4: ASSISTANTS TO MEMBERS IN CHARGE OF GAMFS I
Lisl all members of appliclUIt organization and members of authorized affiliates and auxiliary who will assist with games. Each person listed must be"
member of uppliClllll orj!;unization or affiliate for at lensl I year.
YEARS OF
MEMBER NAME DATE OF BIRTH MEMBERSHIP STREET ADDRESS
G~1 M1TK~) l..{Q / _ / - I - \
I / / 1- \
\-/-/- \ I
1-/-/-\=1
\-/-/-1_1
1-/-/-1_1
1-/-/-1_1
1-/-/- I I
, \-/-/-\-\
'1=/=/= I = \
I / / I_I
\-/-/-1_1
1=/=/= \ - I
1_/_/_1_1
\ / / : I
I-/-/-! -I
I-/-/-! - \
1-/---/- I - I
\- /- /- : - I ;
1-/-/- \ -It
1-/-/-1-1 ,-
1-/-/-1-1
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1=/=/= I = I
I / / I i
1-/-/-1-\
1-'/-/- I = I
1-/-/-1 I
1=/=/= I = I
I / / I I
1-/-/-1-1
1-/-/-'-\
\-/-/-1-
\-/-/-,-
--- -
L fjJ.GC-2A (R~y. 4/03)
Attach additional sheet if necessary.
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CITY
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11111/11111 I 1111/111111 ~IIII ~
Schedule 1: Officers and Directors
WAPPINGER LODGE #2609 OFFICERS for 2005-2006
Title Name Address Town Zip DOB
------------..-------- ------------.-. .......................... .............................. ...-.-........--.-....... .
Exalted Ruler Pamela Kultsar 58 Hillis Terrace Poughkeepsie 12603 02/01/1950
Leading Kgn Derrick Mills Pawling Lake Box 17 Pawling 12564 10/10/1940
LoyalKgn Sandra Seekamp 67 Pawling Lake Pawling 12564 12/10/1945
Lect. Kgn Mark H. Fox 28 Tiger Road Hopewell Jet. 12533 09/15/1957
Esquire Diana M. Cole P.O. Box 549 Hughsonville 12537 04/25/1948
Chaplain Rosemarie Perretta 35 Cathy Road Poughkeepsie 12603 09/0111943
Inner Guard Catherine Rohling 54 Brothers Road Wappinger Falls 12590 04/22/1940
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 James Boyer 134 Andrews Road Lagrangeville 12540 11/28/1937
Trustee Patrick J. Moriarty 26 Robert Lane Wappinger Falls 12590 04/16/1941
Trustee Jacqueline Alfano 93 Brothers Rd. Wappinger Falls 12590 08/27/1938
Trustee Joseph Smith P.O. Box 1972 Poughkeepsie 12601 04/08/1937
Trustee Gerhard P. Stoetzel 662 Noxon Road Poughkeepsie 12803 05/02/1942
Trustee Louis Antolotti 229 Robinson Lane Wappinger Falls 12590 06/23/1933
No Officer receives compensation of any kind.
Schedule 4 Assistants to Members in Charge of Games
First MI
Frank
Philip A
Ralph J.
Henry J
Harold A
Francis J
Roger
Richard 0
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
Boldrin
Crawford Sr.
DeGano
DeJordy
Desruisseau
Dobbins
Drobnak
Fischetti
Fox
Jones
Juhano
Jurina
Minkowski PSVP
Pampalone
Perretta
Sarno
Tucker
Wallner
DOB Address
04/24/1940 39 Kensington Drive
05/16/1937 6 Hackensack Hghts Rd
12/21/1935 12 Thorns 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 Jct
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
--,
I,
GC-2B APPLICATION .FOR GAMES OF
NYS kAClNC, & WMiEI<IN(j BOARD CHANCE LICENSE
I W.ltcl\'liei A\,-, Ex!., Slille 2
1\lhally, NY i12061i1!JK
Td,-,plllllll; \)1 K) 453 K4()O 1 'ax (51 Xl 453 Scl'):.!
www.ral'lllg.slale.lly.llS
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Name 01 ()rga!1lL.atlOn
GC- L~J~J -l_~L~Jq 1- ~JiJ -lol'-~l~ [01&"1 / fOf'l / r 01'1
NYS identification Number Date
SCHEDULE 5 DATES, HOURS AND RENT OF ALL LICENSE PERIODS TO HE HELD
(NOT /lPPLICA.BLE FOR BELL jA.R G.4MES)
DATE
l/ tJl/oC
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HOURS
RENT
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DATE
TIML
PRIZES (Cash or Fall' Market
Value of Merchamlisei
:$ '- '
:$.
:$.
!$.
:$,
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RAFFLES
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SCHEDULE () EXPENSES
Llstltellls or expen:-.e tu he lIH:urred, and the names and addresses of persons 10 he paid.
ITEM UI- LXPENSI:, VL~ND()l< NAME STREET ADDRESS CITY STATE ZIP
C~\ V6- ._ L(1}.11t.~ R~t~~17~(L ~ fl~(1Rd()iLl.-'o(' -~ JC-!il"',v~ ~;;7.; ~
U Q.'-'()~ L.( L1l~~f'~T 1~~'T~p f1.JJUl~':? Uq 7R.(":~1 ~~f~L-~ L),~
L IIJ.(";C.211 (Re>. 4/031
Page I \.)12
IIIIIIIIIU 11111111111111111 ~
r'SCHEDULE 7 TYPES OF GAMES I
.
List all of the single types of games to be conducted at all license periods enumemted in Schedule 5.
Note for Vef!as Nif!hts and Bazaars onlv: The total amount of prizes during anyone license period shall not
aggregate more than $400 for each single type of game of chance when five types of games of chance are to be
conducted during anyone license period. The total amount of prizes during anyone license period shall not
aggregate more than $500 for each single type of games of chance when less than five single types of games of
chance are to be conducted during anyone license period.
LIST NAME OF EACH TYPE OF
GAME OF CHANCE
(Limit: 5 Games)
~t~T~tK.
,76 ((fiR fa /c:lZ-lL
~162- Sl~ w~rt l..--
For Merchandise Wheels, Bell Jars and Raffles. please complete the appropriate spaces below.
MERCHANDISE WHEELS:
INDICATE NUMBER OF
MERCHANDISE WHEELS
(N 0 LIMIT)
THE TOTAL AMOUNT OF PRIZES FOR
EACH MERCHANDISE WHEEL SHALL
NOT EXCEED $10,000 AND NO SINGLE
PRIZE SHALL EXCEED $250
'I'
rl'
BELL JAR:
iNDICATE IF THIS APPLICATION
IS FOR A BELL JAR
LICENSE
YES 0 NO $-.
THE TOTAL AMOUNT OF PAYOUTS
FOR EACH BELL JAR DEAL SHALL NOT
EXCEED $3,000 AND NO SINGLE PRIZE
SHALL EXCEED $500
RAFFLES:
INDICA TE IF THIS APPLICATION
IS FOR A RAFFLE
LICENSE
YES 0 NO j!J-
IF YES, LIST RAFFLE DATES, TIME(S)
OF DRA WING(S) AND PRIZES IN
SCHEDULE 5
THE TOTAL AMOUNT OF PRIZES FOR
ALL THE RAFFLES CONDUCTED DUR-
ING THIS CALENDAR YEAR SHALL
NOT EXCEED $100,000. NO SINGLE
PRIZE SHALL EXCEED $50,000
EXCEPT THAT A SINGLE PRIZE OF
$100,000 MAY BE AWARDED IF SO
INDICATED IN SCHEDULE 5
L IlJ.GC.2B (Rn. 4/03)
Page 2 of 2
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