The 4065 Club Inc
I
MERCHANDISE WHEELS
Merchandise Wheel No. I 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) - Mdse.
(A) (E) (I) Wheel No.2
(C) - Mdse.
Wheel No.3
Merchandise Wheel No.2 Merchandise Wheel No.6 Merchandise Wheel No. 10 (D) - Mdse.
Wheel No.4
Receipts (Less change bank) Receipts (Less change bank) Receipts (Less change bank) (E) - Mdse.
Wheel No.5
Less: Value of Mdse. A warded Less: Value of Mdse. Awarded Less: Value of Mdse. Awarded (F) - Mdse.
Wheel No.6
Profit or (Loss) (B) Profit or (Loss) (F) Profit or (Loss) (1) (G) - Mdse.
Wheel No. 7
(H) - Mdse.
Merchandise Wheel No.3 Merchandise Wheel No.7 Merchandise Wheel No. 11 Wheel No.8
(1) - Mdse.
Receipts (Less change bank) Receipts (Less change bank) Receipts (Less change bank) Wheel No.9
(1) - Mdse.
Less: Value of Mdse. Awarded Less: Value of Mdse. Awarded Less: Value of Mdse. Awarded Wheel No. 10
(K) - Mdse.
Profit or (Loss) Profit or (Loss) Profit or (Loss) Wheel No. 11
(C) (G) (K)
(L) - Mdse.
Wheel No. 12
Merchandise Wheel No.4 Merchandise Wheel No.8 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 Less: Value of Mdse. Awarded (Enter on Line A-3 of GC-7)
Profit or (Loss) (D) Profit or (Loss) (H) Profit or (Loss) (L)
L BJ-GC-7B (Rev. 4/03)
ENTER PROFIT OR (LOSS) FOR EACH TYPE OF GAME ON CORRESPONDING LINE OF CONTROL SUMMARY
Page 2 of 2
11111111111111111111111111111
..., ..
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GC.2
--,
NYS RACING & WAGERING BOARD
I Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (5 I 8) 453-8492
www.racing.state.ny.us
APPLICATION FOR:
PLEASE CHECK
GAMES OF CHANCE D
(Casino Nights, Bazaars, Carnivals)
BELL JAR ~
RAFFLE D
(only raffles wI over $30,000 net profits in calendar year)
~
~OFFICE ~ , 0 5
I USE ONLY Municipal License Number
L---_._____._.
INSTRUCTIONS: PLEASE FILE THREE SIGNED COPIES WITH MUNICIPALITY
GC - CLIiJ - CHLJ]- UJQIL] - ~
N.Y.S. Identification Number
IT IS A MISDEMEANOR TO MAKE ANY FALSE STATEMENTS IN THIS APPLICATION
JOU/'1 of U/"fJ/,"'Il:;@f Jf/v-lc..t.4?,(j
Name of Municipality , , County
$1 ..?.5. 8!.-
Fees Received
0kJ/~/~
Date
2. Address 597 fr-;z Wt:>~/").7"'r...s
3. Has applicant ever been denied a games of chance license? D Yes ~No
;[/r
/..:; S-70
If "yes", why? (Attach ex,tra sheet if necessary)
4. Check type oj organization and, if applicable, give the State and date of incorporation.
Corporation ~
State incorporated A/ Y 5
Incorporated Association D
Unincorporated Association 0
State incorporated
Date IT] / IT] / [ili]
Date IT] / IT] / IT]
Individual
o
5. Did yoU! corporate status change since your identification number was assigned? DYes lilNo
6. Are you doing business under a trade name? 0 Yes ~NO If "yes", what is the trade name?
PARTB. LOCATION OF GAMES
7. Address where games, bell jar, or raffle drawing(s) are to be conducted. ? J 7' ~ c.Ac S- J- U/,/,''h)~YS hll,;
8. Name and address of authorized games of
chance lessor renting to applicant.
9. Does the applicant own the premises? Jll Yes D No If "yes", how long?
I O. Capacity for pub! ic assembly of premises presently owned or occupied.
11. Have premises been regularly used? !;if Yes D No If "yes", how long?
Are games of chance being played now on these premises or has it ever been? DYes
;250
1770
D No If "yes", give full details.
12. Are the premises or any part thereof
where games of chance are to be played
licensed by the Slate Liquor Authority?
~Yes DNo
If "yes", state the t~e of lifense and tlpmber. I ,-ee ,?, e
() 11 F'rto,~ , J ~.J /1 ~ ~'~r
)DC!'?-~ (7w-/c. of 5/()~);l.
13. Has such license ever been If "yes", why? (Explain on a separate sheet, if necessary, and attach.)
revoked or suspended? D Yes ;a No
L BJ.GC.2 (Rev. 4/03)
Page 1 of 2
1111111111111111111111111I111 .J
4
r
PART C. PURPOSES OF GAMES
]4. State the specific purposes for which the entire net proceeds are to be devoted and in what manner.
C he. t d'7 Pc.dr j~o-}: C V 0...11, ;:011/(.. c -I,'&) .,c,/
r)' //
-,
I swear (or affirm):
I. That ALL the atta~hed Schedules are a material part hereof and are incorporated herein as if set out in full in the application. All the answers
contained in this application are a material part hereof.
2. That the entire net proceeds of all games of chance shall be devoted exclusively to one or more of the "lawful purposes" as defined in the Games of
Chance Licensing Law and the Rules and Regulations of the Board.
3. That for each license period for which a license is sought, one or more of the active members under whose supervision the games are to be held,
operated and conducted. who is familiar with the Games of Chance Licensing Law, the Rules and Regulations of the N. Y .S. Racing & Wagering
Board and local licensing ordinances or laws. will be present at all times, in charge and primarily responsible for the conduct of games.
4. That the under'signed 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 localliecnsing ordinances or laws.
5. That the undersigned has read and is familiar with the provisions of the G~hance Licensing Law as amended, the Rules and Regu ations
of the N.Y.S. Racing & Wagering Board, and the local licensing ordi~.~es or laws.
6. That no commission, salary, compensation, reward or recompenseA"ill be paid ~y person for holding or I' gin e op tin r
conducting of the games, except to bookkeepers'9acC$)(61lant~for profi Si~ services in an amount n eedi at fi d b e B
/",,/// / ,/
[!] / rn / lolbl~/ ~ );. [,{jILLJAM 8."'A/VtPOL(
Date Ignature of He Print Name
STATE OF NEW YORK }ss
COUNTY OF b<<l-ches5
Q+Y rrOWNNILI..AGE OF !JJff PI ..u6t"L
(;)( (If A"m "- \ /' ~ fD& ' being duly sworn deposes and says that (s)he is the person above named,
that (s)he has read the foregoing statement and the answer therein noted, and that such answers are true and that (s)he has personally
affixed his (her) signature to this affidavit.
day Of~
, Notary Public
My Commission expires /1,/ 3-;)0 () 9 20
MARIA GILBRIDE
Notary P"blic, State of New Yo"
Re~. No. OlGIS087374 .
Qualifted In Dutchpss County
Commission Expires Nov. 3, ~b()Cj
L BJ.GC.2 (Rev. 4/03)
Page 2 of2
111111I1111111111111 ~ 1/11111 .J
r'
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
-,
[QIJ I I otl~ I I [iliJ
Date
GC-0i]- [lL]fJ-16Iol/l-~
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
?~\.~<<' Il-t )\\\:,,(:~ SCcw'II\()o\~ I r~1 ~h '3> I /hJ. 411.,je fl>..J AI I S-Iofl'f vi/lp I 1)->8-2-
.\~\<~ 100'(6 ~o\-z.. \ I~ I iLl 52-I ,;~ t'hv.-, !IN! ~r I ~pytk"'''rJ,,>,,,1 I~G~J
~~~.I\)lX.,.A ~~\-r.~o I 2- Izo I 5'-t I JJ~ {'6t~ A~ 1 tl7J,j4/1f! I }.)5;JY
Th~~O\ I \S'\\\ \\v../\'t I (0 I 2-D I 4'2- I /()y T()d{~o'~ Sf I F,'-JJ,~,'II I /;l~;1y
\)i.~(jcl ~~~ ~':.S\6:'fJ~1 ~I 65" I SI (!!It-C~(j~d fJ I ;,bt?t?1l'~11 :'1 I /).5'13
\)'~L?C-I ~'~""i ~~~e;, I 5 I 2-'-1 I 57 152- /-tewt\ock, H-,e..r.e- I ~~\. ~<::t II Z;~33
\)\ ~~ I IAJ'A.\\.... LLhjck I!LI ~/'i:j.-' 19J ole! 57Jt'tl-./~..Jj'1/1 /:k;Hw.-1/ ;;--t I J;JS'??
I ' 1_/_1_1 I I
I 1_/_1_1 I I
I 1_/_1_1 I I
I 1_/_1_1 I I
Attach additional sheet if necessary.
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
feJ"'r J [GHI'V~ I---!LI.-1..-1 6sr-1 ;1./ I t;-/ orct.c.n! PIotr->
F }eJ",d 51-1.0/ f I-L I -L 1..fL1 ;2 7 I :2S- C levy" {hI/ t'?, I
We-Ile,- I)/vl-A I -LI ----1-1 .>Y I /y I /y> ~/eI 5)"Jvc" Ic.I<../',11
wid,,,,,.. sC:/>IAf,'-1 ~I :1 I 23-1 'Y 1 J6~ u-J.,Yr fQl-'cl i<eI 1
, 1 I-I I I I
1=/=1=1 1 I
1 I I 1 I I
1=/=1=1 I I
1_/_1_1 1 I
CITY ZIP
Ih-Ji'-.?{,prll hI-I ;>>7 J
J4:;)~ I 1"l6tJ.J
!o/uxt/ Sfl I J >>5 j
S/vrI'1Vi-I(@ I 1')'5d-:L
I
I
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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 AUXILIAR Y/ AFFll1A TE
GAMES OF CHANCE ill NUMBER
L BJ-GC-2A (Rev. 4/03)
Page 10f2
1111/111111111111111111111111 -.J
r
GC-7
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
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, 1 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
OPERATIONS
(Please Print or Type)
Street Address Municipality
Address Where Games are Conducted, if Different:
Zip
County
-,
Zip County
ITJjITJjITJ
Date of License Period Hours of License Period
Street Address
Number of Players
A. RECEIPTS-
1. Admissions (if fee is charged)............................................................................. $
2. Profit or Loss from games other than Merchandise Wheels................................ $
3. ~;~: ~g;~ ~Ou~t ~e~~~;~:::d ':::~t~~~h~d)................................................. $
4. Total Receipts (Add Items 1,2 and 3)................................................................ $
B. EXPENDITURES - (Show only payments actually made)
Describe Expenditure Payee
Check No.
$
$
$
$
$
$
6. Total Expendi tures...................................... ............................... ............ .............. $
C. NET PROFIT OR (LOSS) . $
1. Profit or (Loss) Before Additional License Fee (Item A4 less Item B6)...............
2. Additional License Fee (liST CHECK NUMBER )..................... $
3. Net Profit or (Loss) (Item 1 less Item 2)............................................................... $
D. GAME BANK FUND Payee Check No. Amount
(Memo Entry Only)
E. DISPOSITION 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 balance $
2. Unexpended balance of net proceeds shown on last report..................................
L BJ-GC-7 (Rev. 4/03) Page 1 of2
1. Rent
2. License Fee
3. Games of Chance Equipment
and Supplies
4. Services
5. Other Expenses
. IT]
. IT]
. IT]
. IT]
. IT]
. IT]
. IT]
. IT]
. IT]
. IT]
. IT]
. IT]
. IT]
. IT]
. IT]
. IT]
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I
GC-2B
NYS RACING & WAGERING BOARD
1 Watervliet Ave. Ext., Suite 2
A]bany, NY 12206-]668
Telephone (518) 453-8460 Fax (5] 8) 453-8492
www.racing.state.ny.us
-,
APPLICATION FOR GAMES OF
CHANCE LICENSE
e
Name of Organization
GC-rn-~- ~-1t>111/ Ifl~1
NYS Identification Number
OJIOJIOJ
Date
SCHEDULE 5 DATES, HOURS AND RENT OF ALL LICENSE PERIODS TO BE HELD
(NOT APPLICABLE FOR BELL JAR GAMES)
DATE HOURS RENT
, / . ./. ,am / pm - am / pm $.
" . ,I . , ,I,
. / . . / , ,am / pm - .am / pm $.
,', ,-, ,I,
, / , . / . am / pm - ,am / pm $.
,I . , ,-, ,-,
./ . / . ,am / pm - am / pm $.
,I I ,I . . I',
. / . . / . am / pm - am / pm $.
II . . ,', . ,I,
, / . . / , am / pm - am / pm $.
II . , II . , ,',
,/ , . / , am / pm - .am /pm $.
,I . , .', 1-'
, / . , / , am / pm - .am/pm!$.
,-, , II . ,I,
, / , ./. .am / pm - ,am/pm!$,
,I . ,I . ,',
. / , ./, ,am / pm - .am/pm!$,
,I . ,-, ,',
,/ . ./, I ,am / pm - ,am/pm! $.
, , ,I . ,- , ,',
./ ./ ~-' I .am / pm - .am/pm !$ ,
,I . .' ,-,
RAFFLES PRIZES (Cash or Fair Market
DATE TIME
./~~!. Value of Merchandise)
./ am / pm - am / pm !$ .. . .'.
II . , ,', .
./ I. I . am / pm - am / pm !$.
. . I I II . ,', . ,',
. / . I. I , am / pm - ,am /pm !$
. I . " . ,I. I'.
. / . . / , I am / pm - am / pm 1$.
. I . ,', . . . . . . . .
./ , I . I . am / pm - am / pm !$.
. I . II . . . . ,',
SCHEDULE 6 EXPENSES
List items of expense to be incurred, and the names and addresses of persons to be paid.
ITEM OF EXPENSE VENDOR NAME STREET ADDRESS CITY
STATE ZIP
L BJ-GC.2B (Rev. 4/03)
Page 1 0[2
11111111111111111111111111111 ..J
,
, 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 orJ!;anization or affiliate for at least I year.
YEARS OF
MEMBER NAME . DATE OF BIRTH MEMBERSHIP STREET ADDRESS
I / / 1_'
,-/-/-,-
'-/-/-1-
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,=/=/= , - I
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,-/=/= I = I
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'-/-/-/-1
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'-/-/-'=1
1-/-/-'-'
,-/-/-,-,
1-/-/-1_'
'-/-/-'_1
'-/-/-1_1
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1-/-/-1_1
1-/-/-'-'
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,=/=/= I _ I
1_/_/_1_'
, / / '_I
1-/-/-1_1
1-/-/-1_'
1-/-/-' I
1=/=/= , = I
L BJ-GC-2A (Rev. 4/03)
Attach additional sheet if necessary.
Page 2 of 2
CITY ZIP
, 1
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I
GC-5
--,
LICENSE TO CONDUCT
GAMES OF CIL4--NCE
PLEASE CHECK
GAMES OF CHANCE 0
BELL JAR ~
RAFFLE 0
19!~
NYS r~ACIN:::; L WAGERING BOARD
] Warerv1ie, Ave, EXL., Suitt",
Albany, N'{ 1220(.-1662
Telephone (518) 45?-846U Faj (518) 453-8492
www.ra8ing.srate.n)..us
GC - CUi] - W 1191- [ililiJ- r;Gll
N,Y.S.ldemiflcation Number
This License 'Must Be
Conspicuously Displayed
During Conduct of Games
en I 0 I 6 loW $1 25.00 I [
Municipal Licenst Number Amount of Fee Paid Lessor's License Number
Address: 399 Route 82 City: Wappingers Falls
Entire net proseedE to be devoted to the following specific lawful purpose(s):
CHARITY, PATRIOTIC, YOUTH, EDUCATIONAL
Zip Code: 12590
Names 0;' Members in Charge
Peter J. Cassidy
Floyd Scholz
Walter Wych
William Scampoli
LICENSE PERIOD
DATE DAY OF'VVEEK
YEAR 2006
HOURS
Tl'PE(S) OF GAMES
R.I\FP.1..oE DRAVlING
DATE
DRAWING TIME DRAWING LOCATION
AMOUNT OF RA..l=TLE PRIZES (Cash or Merchandise Prizes
at Fan Market Value)
THE Mi\XIMUM AMOill'<'T OF pRIZES TO BE AWARDED
FOR EACH MERCHANDISE WHEEL
$
I THE MAXIMUM i\MOUJ'H OF PRIZES TO BE AWARDED
FOR EACH TYPE OF GAME OF CHANCE
I $
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.
EACH WHEEL
NUMBER OF WHEELS
GAMES SHALL BE PLAYED IN ACCORDANCE WITH I
STATE LAWS AND RULES AND LOCAL ORDINANCES OR
LAWS.
-<:::. rn..v" (' \ e..(2../L.
(Title of Authorized 0
C.
onzed Officer)
Illl! 11111111 1111 III! 11111111 ~
Issued by -ro-w", of ~f1PPltJulZtt....
g I "( \ ~:' of Municiplliity)
(Date)
L BJ-GC-5 (Rey. 4/03)
I
GC-7B
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
CASH CONTROL REPORT
GAMES OF CHANCE
Organization:
~
I.D. No.:
Date of License Period: IT] / IT] / IT]
Type of Game Type of Game Type of Game Type of Game Type of Game CONTROL SUMMARY
No.1 No.2 No.3 No.4 No.5 PROFIT OR (LOSS)
Number of Number of Number of Number of Number of (A) -
Locations Locations Locations Locations Locations Game No. 1
Starting Starting Starting Starting Starting (B) -
Game No.2
Bank Bank Bank Bank Bank (C) -
Ending Ending Ending Ending Ending Game No.3
Bank Bank Bank Bank Bank
(D) -
Profit or Profit or Profit or Profit or Profit or Game No. 4
(Loss) (Loss) (Loss) (Loss) (Loss) (E) -
(A) (B) (C) (D) (E) Game No.5
ENTER PROFIT OR (LOSS) FOR EACH TYPE OF GAME ON CORRESPONDING LINE OF CONTROL SUMMARY
WORKERS WORKERS WORKERS WORKERS WORKERS
Net Profit
or (Loss)
(Enter on Line A-2 of GC-7)
L BJ-GC-7B (Rev. 4/03)
Page 1 of2
Prepared By
1111111 11111 1111111 III 1111111 -.J
FORM GC-5
Name and Address of lessor:
lessor's license Number:
Identification Number
(from requisition form)
GC 13-219-601-07192
Municipal License Number
0605
AMOUNT OF FEE PAID
$25.00
Form Approved By:
NYS RACING & WAGERING BOARD
BUREAU OF BELL JAR & CHARITABLE
GAMING COMPLIANCE
1 Watervliet Avenue Extension
Suite 2
Albany, New York, 12206-1668
LICENSE TO CONDUCT
GAMES OF CHANCE
This License Must Be Conspicously
Displayed During Conduct of Games
licensee's Name: Address:
The 4065 Club Inc. 339 Route 82 P. O. Box 514 Hooewell Junction NY 12533
Type of license: o Games of Chance I2l Bell Jar o Raffles
Entire Net Proceeds to be devoted to the following lawful purpose(s):
Charity, Patriotic, Youth, Educational
Names and addresses of members in charge of conducting games:
Peter J. Cassidy 51 Orchard Place; Hopewell Junction, NY
Floyd Scholz 2S'C'I'Over Hill Drive; Poughkeepsie, NY 12603
Walter Lynch 193 Old Sylvan Lake Road; Hopewell Junction,
William Scompoli '1a2 'WliiW Pond Road; Stormville, NY 12582
LICENSE PERIOD DAY OF WEEK HOURS TYPE(S) OF GAMES
DATE
Year 2006
RAFFLE DRAWING DRAWING AMOUNT OF RAFFLE PRIZES (Cash or Merchandise Prizes at
DRAWING DATE TIME LOCATION Fair Market Value)
THE MAXIMUM AMOUNT OF PRIZES TO BE THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
AWARDED FOR EACH TYPE OF GAME OF CHANCE FOR EACH MERCHANDISE WHEEL
NUMBER OF GAMES NUMBER OF WHEELS
EACH GAME (Starting Bank) EACH WHEEL
THE TOTAL AMOUNT OF PRIZES FOR EACH BELL JAR GAMES SHALL BE PLAYED IN ACCORDANCE WITH
DEAL SHALL NOT EXCEED $3,000 AND NO SINGLE STATE LAWS AND RULES AND LOCAL ORDINANCES
PRIZE SHALL EXCEED $500. OR LAWS.
ISSUED BY: Town of WappinQer
(Name of Municipality)
DATE: 08/04/2006
(Signature and Title of Authorized Officer)
GC-5 (Rev. 12/94)
4512
THE 4065 CLUB, INC.
845-897-2434
P.O. BOX 514, ROUTE 82
HOPEWELL JUNCTION, ,NY 12533
P~~~:~1_T ~ ,J t.-J~
~ _ ~ fi """~ ~
~Abb
1-1288-260
Date
-.J $-~-: *
--_.,.~._--
-~..,~--,,"",-"
Dollars {D
WACHOVIA BANK, N.A.
WACHOVlA.COM
~~K
For
II- 0 0 0 0.... 5 . 2 II-
27/.. -/l,. .0. I
it' .... .'r
':0 2bO . 2BB .': 20:10 2~~1;17~~ ~II- (.. .-
M'
03/07/2005 07:59 8454620496
.;
SCHOLZ
.~
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3/l tFJ4l1 ~+
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{~Y6 (
PAGE 01
1-/a /J( at.Jj
"117tVL~
~.
F~~ ~o.
DATE ~ .
TIME A.M.
M ~hile You Were Out P.M.
OF~ H-~if _
PHONE 1.LB: '-/11.-.:( 8 $2 :
NUMBER
TELEPHONED EXTENSION
CAME TO SEE YOU
RETURNED YOUR CALL
a_
9711
DA~ /I -' tJ.1/n ..LL<./C-/
TO~
(/JJ u
FROM '--*=dU 1 LJ
~TAPPINGER
SUPERVISOR
JOSEPH RUGGIERO
TOWN COUNCIL
VINtENT BETTINA
MAUREEN McCARTHY
JOSEPH P. PAOLONI
ROBERT L. VALDATI
:RK'S OFFICE
EBUSH ROAD
; FALLS, NY 12590
297-5771
4.5) 298-1478
-
Jonsists of ~
Cover Sheet
pages
JUJ.v.[BER (845) 298-1478
&.olo!J~
/
REFERENCE 1(J~5 JIlt'.
IF YOU DO NOT RECEIVE ALL THE PAGES, PLEASE CONTACT
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GC-5
I
LICENSE TO CONDUCT
GAMES OF CR4..NCE
PLEASE CfillCK
GAMES OF CHANCE 0
BELL JAR ~
r..AFFLE 0
GC - GJi] - Will. G:liIiJ - c:wIWJ2J
N.Y.S. IdentifIcatioTJ Number
NYS RACINe & WAGERING BOARD
1 Wlltervliet Avt. Exl., Suite 2
Albany, NY 1.2206-1668
Telephone (5J B) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
Zi,
This License J\1.ust Be
Conspicuously Displayed
During Conduct of Games
$/ 25 . 00 II I
Amount of Fee Paid Lessor's License Number
A.ddress: 399 Route 82 City: 'Wappingers Falls
Entire net proceeds La be devoted to the following specific lawful purpose(s):
CHARITY, PATRIOTIC, YOUTH, EDUCATIONAL
Names of Members in Charge
Peter J. Cassidy
Floyd Scholz
Walter 'Wych
William Scampoli
LICENSE PERIOD
DATE DAY OFvVEEK
Zip Code: 12590
HOURS
Tl'PE(S) OF GA.lvIBS
YEAR 2006
RAFFLE DRA VyING
DATE
DRA VirrNG TIME DRA 'WING LOCATION
AMOUNT OF RAFFLE PRIZES (Cash or Merchandise Pri=
at Fan Markel Value)
THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
FOE EACH TYPE OF GAME OF CHANCE
.$
THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
FOR EACH MERCHANDISE 'WHEEL
$
EACH WHEEL
NUMBER OF GAMES
EACH GAME (Starting Bank)
NUMBE]~ OF WHEELS
THE TOTAL AMOUNT OF PRIZES FOR EACH BEll.. JAR
DEAL SHALL NOT EXCEED $3,000 AND NO SINGLE PRIZE
SHALL EXCEED $500.
Issued by (" o-w t"\ of W f\ pp, tJ Ci 12 ~
8' (l-I \ ~:' ofMu,icip,lity)
\ (Date)
L BJ-GC-5 (Re1'.4/03)
GAMES SHAll BE PLA1'ED IN ACCORDANCE \VITH ]
STATE LAWS AND RULES AND LOCAL ORDINANCES OR
LAWS.
~o-w" C \.e.(2.~
(Title of Authorized 0
Co
OTlzed Officer)
1IIIII1I111I111I1I11111IIIlII .-J
,,'
I
GC-7B
NYS RACING & WAGERING BOARD
I WatervIiet 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
I
Organization:
i.b:No.:
Date; of License Period:U] / U] / rn
Type of Game Type of Game - rc. '"TyPe of Gaih~ Type of Game "- "<'Type of Game CONTROL SUMMARY
No. 1 No.2 No.3 No.4 No.5 PROFIT OR (LOSS)
Number of Number of Number of Nwnber of ,_,~umber of ' " (A) -
i Locatiriris Game No. 1
Locations Locations Locations Locations
- '. jlC,;"-' .- " '. ., . -~l (B) -
"
Starting Starting Starting Starting Starting Game No.2
Bank Bank Bank , "",co- , ,:;:,~ ~ Bank :0: :., " ' 1 ,~ . Bank ;':1
(C) -
Ending Ending En.ding ; Ending .- " ,," Endil1~ -- Game No.3
Bank Bank B~' Bank "- ~. ,; :. Batik -'
(D)-
Profit or Profit or Profit or' Profit or Profit or Game No~ 4
(Loss) (Loss) .~ -. ".'.-,...-.- (Loss), " (Loss)'.--- , ;i:'il (Loss) -",. .>"
(A) (B) (C) (0) (E) (E)-
ENTER PROFIT OR (LOSS) FOR EACH TYPE OF GAME ON CORRESPONDING LINE OF CONTROE'SUMMARY Game No.5
WORKERS WORKERS WORKERS WORKERS h WORKERS ,
Net Profit
. or (Loss)
(Enter on Line A-2 of GC-7)
~.,
.;
( ,
,
f .
Prepared By
11111111111111111111111111111 ~
L BJ-GC-7B (Rev. 4/03)
Page 1 of2
',arded ___ LeSS: Value of Mdse. Awarded --- Less: Va\ue of Mdse. Awarded--
MERCHANDISE WHEELS
\
Merchandise Wheel No.9
Receipts (LeSS change banl<) ___ Receipts (LeSS chauge baul<) --- Receipts (LeSS change bank) --
Merchandise Wheel No.5
LesS: Value of Mdse. Awarded ___ Less: Value of Mdse. Awarded -- LeSS: Value of Mdse. Awarded---
Merchandise Wheel No.1
- -
_ Profit or (LOSS)
-(B) - Profit or (Loss)
(1)
Merchandise Wheel No. 10
Profit or (LOSS)
-
(A)
--
Merchandise Wheel No.6
--
Receipts (Less change bank)
LesS: Va\Ue of Mdse. Awarded ___ LeSS: Value of Mdse. Awarded --- Less: Value of Mdse. Awarded---
Merchandise Wheel No.2
Receipts (Less change bank)
--
Receipts (LeSS change bank)
_ Profit or (Loss)
-
_ Profit or (Loss)
-(F)
ProHt or (LOSS)
(B)
Merchandise Wheel No. 11
Merchandise Wheel No. I
--
Receipts (LeSS change bank)
Merchandise Wheel No.3
Receipts (LeSS change bank)
--
Receipts r
""lnge bank)
-(G) profrt or (LoSS)
Less: ~
Profit or (LOSS)
Merchandise Wheel No. 12
-::::-
I
py
___ Receipts (LeSs change banl<)
-r.~
~"s change bank)
--
CONTROL SUMMARY
PROFtI OR (LOSS)
-
(A) - Mdse.
Wheel No. 1
(B) - Mdse.
Wheel No.2
(C) - Mdse.
Wheel No.3
(D) - Mdse.
Wheel No.4
(E) - Mdse.
Wheel No.5
(F) - Mdse.
Wheel No.6
_ (0) - Mdse.
(J) Wheel No. I
(ll) - Mdse.
Wheel No.8
(1) - Mdse.
Wheel No.9
(n - Mdse.
Wheel No. 10
(R) - Mdse.
Wheel No. 11
--
-------
-------
-------
-------
------
------
------
-------
------
-------
-----
-(K)-
(L) - Mdse.
Wheel No. 12 ------
--
Net ProHt
or (LOSS) ---------=-:
(Buter ou Line A-3 of G(
. Awarded-- Less: Value of Mdse. Awarded--
_ Profit or (LOSS)
-(L)
~~\\\\\"\\\~,
-
(ll)
~"lD1l'lG L1l'lB OF CONTROL SUMMAR'l
. _.,,,._. '-JV-""
Form Arproved By:
NYS RACING & WAGERING BOARD
BUREAU OF BELL JAR & CHARITABLE
GAMING COMPLIANCE
1 Watervliet Avenue Extension
Suite 2
Albany, New York, 12206-1668
LICENSE TO CONDUCT
GAMES OF CHANCE
Identification Number
(from requisition form)
GC 13-219-601-07192
Municipal License Number
0605
This License Must Be Conspicously
Displayed During Conduct of Games
Name and Address of Lessor: Lessor's License Number: AMOUNT OF FEE PAID
$25.00
Licensee's Name: I Address:
The 4065 Club Inc. 339 Route 82 P. O. Box 514 Hopewell Junction NY 12533
Type of License: o Games of Chance 121 Bell Jar o Raffles
Entire Net Proceeds to be devoted to the following lawful purpose(s):
Charity, Patriotic, Youth, Educational
Names and addresses of members in charge of conducting games:
Peter J. Cassidy 51 Orchard Piace; Hopewell Junction, NY
Floyd Scholz 2S'C'Iover HlII Drive; Poughkeepsie, NY 12603
Waller Lynch 193 Old Sylvan Lake Road; Hopewell Junction,
William Scompoli ~1:)2 W/'iiP& Pond Road; Stormvllle, NY 12582
LICENSE PERIOD DAY OF WEEK HOURS TYPE(S) OF GAMES
DATE
Year 2006
RAFFLE DRAWING DRAWING AMOUNT OF RAFFLE PRIZES (Cash or Merchandise Prizes at
DRAWING DATE TIME LOCATION Fair Market Value)
THE MAXIMUM AMOUNT OF PRIZES TO BE THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
AW ARDED FOR EACH TYPE OF GAME OF CHANCE FOR EACH MERCHANDISE WHEEL
NUMBER OF GAMES NUMBER OF WHEELS
EACH GAME (Starting Bank) EACH WHEEL
THE TOTAL AMOUNT OF PRIZES FOR EACH BELL JAR GAMES SHALL BE PLAYED IN ACCORDANCE WITH
DEAL SHALL NOT EXCEED $3,000 AND NO SINGLE STATE LAWS AND RULES AND LOCAL ORDINANCES
PRIZE SHALL EXCEED $500. OR LAWS.
ISSUED BY: Town of WappinQer
(Name of Municipality)
DATE: 08/04/2006
(Signature and Titie of Authorized Officer)
>5 (Rev. 12/94)
HP Officejet 7210
Personal Printer/Fax/CopierlScanner
Log for
Town Wappinger Code Enfor
845-297-0579
Dee 26 2006 12:31PM
Last Transaction
Date Time
~
Dee 26 12:29PM Fax Sent
Identification
Duration PaQes Result
12124172160
1 :12
5
OK