Wappinger Elks Lodge 2609
LICENSE TO CONDUCT
GAMES OF CHANCE
PLEASE CHECK
GAMES OF CHANCE ~
BELL JAR 0
RAFFLE 0
GC - [iliJ - ~- [ilili] - CiliIililiJ
N.Y.S. Identification Number
.
r
GC.S
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
This License Must Be
Conspicuously Displayed
During Conduct of Games
$/ 50.00 II I
Amount of Fee Paid Lessor's License Number
Address: 1195 Rt. 376 City: Wapp i ngers Fa 115
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: 1 2590
Rich Dobbins
Simon Kaufman
Lew Hakim
LICENSE PERIOD
DATE
10/06/2006
11/03/2006
DAY OF '\VEEK
Friday
Friday
HOURS
7:00pm - 1:00am
7:00pm - 1:00am
TYPE(S) OF GAMES
Blackiack. Joker Poker. Biq Six
Blackjack, Joker Poker, Big Six
RAFFLE DRAWING
DATE
DRAWING TIME
DRAWING LOCATION
AMOUNT OF RAFFLE PRIZES (Cas~ or Merchandise Prizes
at FlIIr Market Value)
THE MAXIMUM AMOUNT OF PRIZES'
FOR EACH TYPE OF GAME OF CHANe
$
E'AC'H
NUMBER OF GAMES
If ' , -.,
.. 0" /',P V
.: \or ,/
;1 .. !~._".
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~/
7
t.t._ ?-( t? /Z,L-.1'-'"']
V ~;
')./ I'
//~ ~/ C c.
\XIMUM AMOUNT OF PRIZES TO BE AWARDED
.CH MERCHANDISE WHEEL
$
~ER OF WHEELS
EACH WHEEL
THE TOTAL AMOUNT OF PRIZES FOR]
DEAL SHALL NOT EXCEED $3,000 AND NU :SlNVLn Y.K1L.C
SHALL EXCEED $500.
~HALL BE PLAYED IN ACCORDANCE WITH
l~l.n.H'; ...,AWS AND RULES AND LOCAL ORDINANCES OR
LAWS.
Issued by
TOWN OF WAPPINGER
(Name of Municipality)
crt dO 10(0
(Date)
L BJ-GC-S (Rev. 4/03)
uthorized Officer)
1111111111I" 111/111/11/11111 -.J
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GC-4
NYS RACING & WAGERING BOARD
] Waterv]iet Ave. Ext., Suite 2
Albany, NY ]2206-]668
Telephone (5] 8) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
FINDINGS AND
DETERMINA TION
FOR GAMES OF CHANCE
LICENSE
GC-rn-~-~-~
N.Y.S. Identification Number
I
TOWN OF WAPPINGER
Name of Municipality
1195 Rt. 376, Wappingers Falls, NY 12590
Address
~al Law, the following findings and detenninations
. /
of chance are of good moral lS(:es 0 No
Title ~ \,CCl ff
After investigation, and a hearing if required under Sec. 192 of the General
have been made:
1. All the members-in-charge designated in the appli
character and have never been convicted of a c .
Signature of Person Conducting Investigatio'!'
2. Applicant is a qualified authorized organization as defined in the Games of Chance Licensing Law.
3. All the members designated in the application to conduct games are bona fide active members of the applicant
organization.
4. The premises presently owned or occupied by the applicant are in every respect adequate and suitable for
conducting games of chance.
5. The games of chance are to be conducted in accordance with the provisions of the Garnes 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
Garnes 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)
n/a
~Yes DNa
Ii3 Yes DNa
~Yes DNa
IXI Yes DNo
/XI Yes DNa
~Yes DNa
tKJ Yes DNa
I[] Yes DNa
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 Sept. 8, 2006 Authorized Officer
Date ~ 0& 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) 1111111111111111111111111 1111 -.J
r-
GC-2A APPLICATION FOR GAMES OF CHANCE LICENSE
NYS RACING & WAGERING BOARD
I Watervliet Ave. Ext.. Suite 2
Albany, NY 12206-1668
Telephone (518) 453.8460 Fax (518) 453-8492
www.racing.statc.ny.us
--,
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Name of Organization
GC- rn - [JIDj] - [IITill- [QJiliJillJ
NYS Identification Number
SCHEDULE 1: OFFICERS AND DIRECTORS
US( names, addresses and dales of blnh of all officers.
If organization is a corporation, or an incorporated or unincorporated associalion. Iisl officers and directors.
TITLE N~~, I'.IL", DATEQ{B~TH STREET ADDRESS CITY
IC'71!~ ~~!lt-L/_I I
I 1_/_/_1 I
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1 1_/_/_ I
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I 1_1_1_' I
I 1_/_/_1 I
I 1_/_/_1 I
I 1_/_/_1 I
I I_/~L<-I I
.,,,,11.
Attach additional sheet if necessary.
MEMBERSINCHKRGEOFGAMES
(MUST LIST AT LEAST fOUR MEMBERS Of APPLICANT ORGANIZATION)
DATE YEARS OF
NAME OF BIRTH MEMBERSHIP STREET ADDRESS CITY ZIP
?~L ~~0l~~1 l:Q../ "S-I-LLI\;Y AJJl)R~w;"OJ~ptt',~ ,~S41)
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L..~ tal<\ V\ l-.::L 1 -B-l \f C; I 3 I )..'j ~~ ~U! '4 ~r' .\Fk,L ~ ()-S"" q-o
I 1 1 I' I I
,-/-/-, I I 1
'-1-/-' I I ,
1-/-/-1 I I I
1=/=/=' I I I
I 01 Ofl 1 [TI 1 @ill
Date
ZIP
SCHEDULE 2:
SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM Of 2 AUXll.Lo\RIESlAffD..IATES. EACH AUXD..IARY/AFFnJATE USTED MUST HAVE ITS OWN ID NUMBER.)
NAME OF AU~YIAFFIllATE
L BJ-GC-2A (Rn.4/03)
GAMES OF CHANCE In NUMBER
Page 1 of 2
III IIIIIII~ III ~ 1111/111111 -.J
~
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
September 8, 2006
Adrian Anderson, Sheriff
150 North Hamilton Street
Poughkeepsie, NY 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 conducting Games of Chance on
October 6, 2006 and November 3, 2006.
I would appreciate your review of the application and completion of the "Findings and
Determination" form attached.
Thank you for your attention to this request and your prompt reply.
Yours truly,
John C. Masterson
Town Clerk
Smk
Ene.
r
GC-4
NYS RACrNG & 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
FINDINGS AND
DETERMINA TION
FOR GAMES OF CHAN'CE
LICENSE
I
GC - rn - G!J - [iliJ3J - CQI1IQILG]
N.Y.S. Identification Number
TOWN OF WAPPINGER
Name of Municipality
1195 Rt. 376, Wappingers Falls, NY 12590
Address
After investigation, and a hearing if required under Sec. 192 of the General Municipal Law, the following findings and deternrinations
have been made:
1. All the members-in-charge designated in the application to conduct games of chance are of good moral
character and have never been convicted of a crime.
Signature of Person Conducting Investigation
Title
DYes DNo
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)
n/a
DYes DNo
DYes DNa
DYes DNa
DYes DNa
DYes DNa
DYes DNo
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 0; license is DENIED 0
Signature of
Filing date of Application Sept. 8, 2006 Authorized Officer
Date
Title
TOWN CLERK
(Municipal Licensing Authority)
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 IlJ-GC-4 (Rev. 4/03)
11111111111111111111111111111 -.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
--,
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Name of Organization
GC- [ill] - ~ - [ffiU] - ~
NYS Identification Number
SCHEDULE 1: OFFICERS AND DIRECTORS
Ust names, addresses and dales of blnh of all officers.
If organization is a corporation. or an incorporated or unincorporated association. Iisl officers and directors.
TITLE N~.,.-1\, II.z"" DATE Q{ BIRTH STREET ADDRESS CITY
IC~1Z~ trH1t-~I~!:lt.LI _I I
I 1_1_1_' I
I 1_1_1_1 I
I 1_1_1_1 I
I 1_1_1_1 I
1 1_1_1_1 I
I 1_1_1_' I
I 1_1_1_1 I
I 1_1_1_1 I
I 1_1_1_1 I
1 I_I ~i++--.I 1
Attach additional sheet if necessary.
MEMBERS IN CHKRGE OF GAMES
(MUST LIST AT LEAST FOUR MEMBERS OF APPLICANT ORGANIZATION)
DATE YEARS OF
NAME OF BIRTH MEMBERSHIP STREET ADDRESS CITY ZIP
~~L ~~~~I lfLI ~S-I---LLI\~ AJ.1~~~R()j~pt.Ii'I~ 1~SL(1)
~\Lt+- f)o~f.>\V1 5' I:2QI ~I~I to ~ ~~ Q{? I~()e ~~ 1 td--~~
C;\.40\l l<~"'" '61 --L.k.-I ~I~I <t SolfT1t'- v'l~Ut t.iJ 1~~~.. ':It!t-, I \J...~; ~
t...~ tal~\~ I ~I -B-1 'f~ I 3 I:>-~ ~~ RrtJU! ~ ~\U~(J .""~L~ ()-S""q'O
I I I I 1 I I
'-1-1-' I I ,
1=1=1=1 I I I
I I 1 I I I I
1=1=1=1 I I I
I 01 ~I I ~ I [g]
Date
ZIP
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 AU~Y/AFFlllATE
L BJ.GC.2A (Rev. 4/03)
GAMES OF CHANCE ID NUMBER
1I11111111~ 11111111I111 ~III .J
Page 1 of2
,-,:'
(>~l)
l G-'''''K SIMON KAUFMAN
ERNA KAUFMAN
9 SOUTH VIEW LANE
i . HOPEWELL JUNCTION, NY 12533
50-235/219 C) ')
561 216 CP
Date~ ok
$ 9J 1I-r-;0
_.
][Yay to the
Order of
Dollars
~ con1ains.saClJfilY
Feal:.Jfes, Details
t on Back
]FOR" ~
I: 0 2. 90 2 :3
27~IOlb5~1I' ~~ ·
t9CHECK GALLERY, 1995 STYLE # p03 1-800-354-3540 www.checkgallery.com
PRINTED ON RECYCLED PAPER USING VEGETABlE:-BASED INKS
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GC-2
I
FOR OFFICE
USE ONLY
APPLICATION FOR:
PLEASE CHECK
GAMES OF CHANCE 0
BELL JAR 0
RAFFLE 0
$1 SC. ~.!.
Fees Received
NYS RACING & WAGERING BOARD
] Walervliel Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.st8Ie.ny.us
[ill] / ~ / [ill]
Date
INSTRUCTIONS: PLEASE FILE THREE SIGNED COPIES WITH MUNICIPALITY
GC - []]]J - ~- []JQJiJ - ~
N.Y.S. Identification Number
IT IS A MISDEMEANOR TO MAKE ANY FALSE STATEMENTS IN THIS APPLICATION
TDw tJ t9 P' wA-f'Pt tJ~R \)VTC\l--f!5 ~
Name of Municipality County
2. Address
3. Has applicant ever been denied a games of chance license? 0 Yes
4. Check type of organization and. if applicable. give the State and date of incorporation.
Corporation 0
~ State incorporated \J ~ " A fl V_
Incorporated Association ~ ~ -
Date ~ / [M] / [ill]
Date []] / []] / CD
Unincorporated Association 0
State incorporated
Indi vidual
o
5. Did your corporate status change since your identification nu~ber was assigned?
DYes
~o
6. Are you uoing business under a trade name? 0 Yes 0 No If "yes". what is the trade name?
PART B. LOCATION OF GAMES
7. Address where games, bell jar, or raffle drawing(s) are to be conducted. ( { 'tS'"' ~. ~ '"/G,
8. Name and address of authorized games of \.J I i"\
chance lessor renting to applicant. rJ
9. Does the applicant own the premises? rJ::<es 0 No If "yes", how long?
wA- Pf, f2t} lJh 1-..0.'\
I
~~G:,
11. Have premises been regularly used?~Yes 0 No If "yes", how long? t ~~.!:?
Are games of chance being played now on these premises OJ' has it ever been?)tYes 0 No If "yes", give full details.
A-vC-. 'D Y l J-OO ~
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?
J O. Capacity for public assembly of premises presently owned or occupied.
If "yes", slate the type of license and number.
CL ~ COO/t.{ -J-lf j
13. Has such license ever been If "yes", why? (Explain on a separate sheet, if necessary, and attach.)
revoked or suspended? 0 Yes ~o
L 8J.GC.2 (Kev. 4/03)
Page 1 of2
11111111111111111111111111111 --l
I'
I
PART C, I'l'l{I'OSES OF C;At\'lE.'i
1'1 ~~:Il,i! lll~ SP(l't~PlljE~RV.~OOl~lll"1 plm:t.:eds ,lie to l~l
~\)lC'.d alld ill what 11Ji\l\ller.
of~Rrt-ll D~ S,
I S '.\ l:~Ci i \ l il .I (Il !'llll
nt.11 :\It. Itle :lll'lcllell ,",'ilr~dllk.s ai'\~ a Illall'.llill p,IJlllelel>rillld ,III: illcoq.J\J1aled IIClt\!1 as ii :>e,luUIIII full illlhe applicillIOII, I\llllle 4il>WC:I,
,'1>1114111<:[\111 .liis 4pplic'lllUlI Hrt: " Illall.:na! pw I Ilell.:ol.
I hUII/IC <:IIIIIC 111.:1 pl\1cc~d, 0\ 1111 gUllIc,) of dHU1C~ ~hull b~ devoted exclu$ivcly 10 olle 111' more llr the "Iawlul purposes" as \tet1ned in [he Galllcs uf
(,b'le<: Lj,'cll,in8 L."", dnJ lilt: I{ules d[\(1 f{,'gulaliolls "llh~ H()anl.
i.
lil~ltor t'~l'.li il,:en,c I.x:ri,.>u tor wllich a Ike.il.1r. IS suugllt, Llllt: III 1II0le (lithe U,lIl'e IIleJIIIJ<:rs IIllUeJ whu~e $lIpervisiLllltht: gUllies are to be he;c,
\)"l;'lillC': 41lJ cUIlJuctc:U, wilu i.~ tUlIlili;lr wilh the: GUIl\~S of CIIUIlCC Liccnsing Law, Ihe Rules iilllll{tlgulalion$ ot tile N, Y,5, Ra,:lllg &. Wll~enl:g
LiuUIU illlJ Ixullictlllsillg vldill,lIlCCS 'JJ' JiIIVS, will he [lr,'.sl~lIll1l .Jillill\t:S, in dlalge und pJiJllwil)' IC'I'UII:;iLJIe fOI UIC C:UIlJUCI of gamc:;,
4,
III~\ IIIC llmlelsigneJ will tll' 1"SpUIISlbk I,llthe IIOldillg, (lIH~rali(jllIIlILi c(lIldllCI (If ,ill glllllc, uf dlllllU; in ~cclJldaocc with thc Icum of the I1cclls,.,
tile i;J ,,' "iul\.) \II ',he C;,I,IIlC,' vi' ChlJrlce UCCIl,)JIIt( I "IW, IIle l{lIk~; Hod Regulatiuns of the N, Y .S, I\tlclng <I:: Wageriog !:loaret ami wittl tlie PI(WI)IUil'
'.II i",'d, illeo"illg un.i/II;lllc'CS 01 LIW$,
llllll II" lIJIJc'ISlgnc:..Iltas read and IS IUolill'lr wllh llle [lJ'\lvisi\lll.\ i1r tlie CiHIII<;:S \Ii' CIIUII\;C LlceJlslllg Lm <i, iUllcmlccJ, tli, l{lIks ilod Rrgui,'liulb
,'I ii\~ .\ '1 S I\d(\il~ & \\ .tgcflng Ik,ucl, UI\U Iii" 1,lntl JiC<:IISlllg onlillullcCS UI laws,
(),
lliill lid ,'\llllllllS,iull, SdlMY, COIIlPC,II"illil)t1, rew'li'd or recompense willl1~ paid to any persoll ror tloldlll<\ or <l$$isling III tll~ ope!'ullllg or
,'I:I,jllc'IIlI~. l,r IIIC gUll...", C.\L'C.p1 to buuU,('el'cls Dr aCCOll111i1llls rur jllDl<::ssiulIUI services ill all 1IJIIUI\lll (Iul e,~ccediJlg tltal iixeo by the BO(l\d.
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iT:;I':;-}:: ii:~:',:;;~rlii;::-T:;-r:;~::;I;;g;-;lt(;,lll~-;it-,~i;Jlhc ;mswel: lill:H:'III Illlll.:d, aIll! [hul SUL'l1 answers an~ trlle and thill (s)h.: has personally
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Commissi()m~r of [kcds
:\h c.lillllli"s;UII l',\jJin:s ___
\~S,.:_.~). L_. '20 _Q_~
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SARA J. DOBBINS
Notary Public. State of New York
Qualified in Dutchess County
Commission No. 01004865746
t'ornmission Expires July 21, ~i
L tIJ-LC,2 d{o, ~i(J.1!
[1(\gc2 'J I ~
11\ 11111 111111111111111\ \\111 ~
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GC-2A
I
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
f r \
Name of Organization
GC- rn - [JJil]] - [ffiUJ - [QIili[illJ
NYS Identification Number
SCHEDULE 1: OFFICERS AND DIRECTORS
List names, addresses and dales of binh of all officers.
If organization is a corporation, or an incorporated or unincorporated association, list officers and directors.
TITLE NAM~, I'./Z...... DATE Of BIRTH STREET ADDRESS CITY
IL'71!~ ~1~1--LI_1 1
I 1_1_1_1 1
I 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 1_1_1_1
1_1_1_1
1_1_1_1
I_I_L+-I
....."
Attach additional sheet if necessary.
MEMBERSINC~RGEOFGAMES
(MUST LIST AT lEAST FOUR MEMBERS OF APPLICANT ORGANIZATION)
DATE YEARS OF
NAME OF BIRTH MEMBERSHIP STREET ADDRESS CITY ZIP
?il-vL ~aOtt~~1 ;}.() 1 "S-I--1LI\~ IW~~~RO .1~VPi~ILJ4..: 'J-St{1>
f{\L\~ f)op,~ \..,1, 5' 1 ?yO 1 ~I (q 1 Go ~ lJ-Uf?J..fi- \.) R. Iw~()P .~ 1 t ~ S1 t?
~\.\.{Ov' l<~~ '61 --1.JLI 3.Q1~1 <t ~lft1It- Vt~lJI L.i.J ,~(>~.. 'Jt!t' I \')..~; ~
l.-Iilu \:d:A:J<(\ V\ I ~ 1 ...B.. 1 'f ~ I 3 I J-? ~~ ~ ~ ~ \u ~ (J .\Fk-L ~ ()- ~'""' q1>
, I 1 1 1 1 I I
1-1-1-1 1 I I
1-1-1-1 1 I 1
1-1-1-1 1 I 1
I=I=/=! I I I
loIOfI/~/@m
Date
ZIP
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 AUAY/AFFlllATE
L BJ.GC.2A (Rev. 4/03)
GAMES OF CHANCE ill NUMBER
Page 1 of 2
11I11111111111111111111 ~III .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 npplicant organization or afflliate for at least] year,
YEARS OF
MEMBER NAME DATE OF BIRTH MEMBERSHIP STREET ADDRESS
I / / I_I
(c,~ 1=(=1= I _ 1
r:1-J~I_/ _/ _ I _ I
b.-\~} I / / I _ I
-/-/-1 I
-/-/- -I
1-/-/- = I
1-/-/-1 1
1-/-/-1 = I
1-1-/-- I I
1'--- /-----/- I = I
1'-/-/-1_1
,----- /- /- I I
1-/-/-1=1
1- /--/-'- I I
1-(-/- I - I
1-/-/-1 = I
1=/=/= I _ I
I / 1 I I
1=1=1= I = I i
1 1 I I
-/-/-1-'
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1-/-/-1_1
\-/--/-1 I
1-/--/-1 = I
1--/-/- I _ I
1--/-/-1_1
1-/-/-1 I
'-/-/-1 = I
-/-/-1_1
--/-/-1_1
1-/--/- I _ I
1=1=1= I _ I
/_/_/_1_1
L BJ.GC-2A (Rev. 4/03)
Attach additional sheet if necessary.
Page 2 of 2
CITY ZIP
I
I
I
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I
I
I
I
I
I
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11111111111111111111111111111 .J
Schedule 1: Officers and Directors
WAPPINGER LODGE #2609 OFFICERS for 2005-2006
Title Name Address Town - Zip DOB
---------------------- --------------- ---------------- ------------- ------------ ------.
Exalted Ruler Steve Drobnak 53 Moccasin View Rd. Fishkill 12524 02/02/1957
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 Pawting 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 04/16/1941
Trustee Paul U. Bader 366 Andrews Rd. Lagrangeville 12540 09/20/1965
Trustee Harris Jones 102 Brothers Road Stormville 12582 04/24/1944
Trustee Gerhard P. Stoetzel 662 Noxon Road Poughkeepsie 12603 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 O.
Richard D.
Stephen F.
Robert
Mark H.
Harris C.
Robert J.
Joseph
WilliamK.
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
Ju~ano
Jurina
Minkowski PSVP
Pampa/one
Perretta
Sarno
Tucker
Wallner
DaB 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
t,
APPLICATION H)R GAMES OF
CHANCE LICENSE
.
t,A ..: " ';
, , " ~
~>~ ";
NYS KACINC; & WAl ifl{IN(, !10AIW
! Wal<:rviJel A", E;;t., S\lJle 2.
Alhany, NY 12.2()(j..IN1K
Tckphollc (51 H) 45J.84()() Fux 15 I Xl 453 K4()2
www.ra..llIg.slaleny.lls
~! ~f If I \ l~I~~l~~=l!{~~,ld oIP~
Nall1t: or OrgalllL,alJOn
GC- ffil- [Jlil<il - I ~ loT~l- fOl<r1 0 I \ 13l [-~r9j / ID)-i'] / roT~ I
NYS Identification Number Date
SCHEDULE 5 DATES, HOURS AND RENT OF ALL LICENSE PERIODS TO HE HELD
(NOT flPPLlCABLE FOR BELL JAR GAMES)
DATE
~JQ~ / ~ / Q..~,
~-LL / .Q,l> / ~_Qfz
I /
......_--t-_, _.~.... F.-.--'-.-.---l ...___._..o....--....i
~~/_~/,
~----J / ....----L--I I ~...
/ /
l...._.__........_.___-i l...____.~._.._u~ ; ,___,_,~ _______,
I I
'------'---I "-----..............__... '-___..........0-.---<
/ I
~_.-J L..---...lo......-<. l.--_.-..I...--J
I /
J,,--,-_~..~..J ~_,._~_~._,..__... ....____.._~__.,__._,
/ /
~__.___._._...... '-~_.____t l-,...__~_...._.,
.._~._, / __,~.~ I ,__~_._.,
~~~ / __~~ I ,_~__,
HOURS
RENT
~__~__, : ,~~~ Om / @). ~__~J: ~.a~QH.@pm i $ ,
'---'-~ : .1l0J2 am / @>, ,~.l: ~~ @pm $ ,
._.~~ ' ,am / pm ~---'---' . , , am / pm i $ ,
_~~ : __.,---,am / pm . ,___~__~: .,~~.__., am / pm I $ ~~~
~__.~__,~. ~_-'---' am / pm . ~---'--' arn / pm i $
'......~ ...0' ~_._,____YIl1 / pm '_.--,--<' ~----"---' am / pm $, , ,~~ '
~_~,_~. ,-~___.Ylll / pm .. ~~_~. ~,_~_",am / pm ! $ ~___~_~.~____'____"' ~_~...__,
am / pm $ ,
.._ ,. L . ~ . ,___.....__.ym I pm , . ~-'----' a III / P III $ 1--....
"..__~____: _.__~ am I pill ' ~~~ alll / pm '$ ~.
~,,_......_____o ,am/pm'I>' , , ,aIn/pm i$_
,.._~_".~. ._~__~_yrn I pm- .__~___ .....~._}lm / pm $
~_.~~__ . '------'-------' ,U11 / P ill
_',_.,__l
..~~
DATE
TIME
PRIZES (Cash or Fair Markel
Value of Merchandisd
,$---,
!$,
,$. .
$~,
$~
RAFFI"ES
.___.~,' / ~__ / '-_~_," , ~_. ~_ ~ am / pm
._.....~__~ I ~~__~ / ~~~ 1 ~_~____: ~..._~___. am I pm
~..'~_. / ~__..,~~ / ~.__~_~ '_ .,_ __ , . ,__,---, a III / pm
I / am / pm
lo_._........,.~_---' _____--..I '"----"-_.~..,l l.-_ _ .... ____~. .. ~__........4
~~ I , . / : am I pm
L_.~.. ._.l....___ .....; .~...~~_A--_--.J
, . ,__.~~ am I pm
.,,_~_--,' ~___~_~aln I pIli
. am I pm
~.._~,_.,....I..--....I l..,_--J..--.-l
am I pm
.-.I.l.-~
. ~---"--'"
"
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. am I pm
L..... ___...1...-......_-1 ._~__.--.,_._--J
. . lo--~
SCHEDlJl.E 6 EXPENSES
List Items of expense to be lllcurrcd, and the names and addresses of persons lo be paid,
JTEM OF EXPENSE VENDOl< NAME STREET ADDRESS CITY STATE
~l1Jrr ~~~LJ{, f'n.n ~\,"O~ L~3er;~~'
tA<U.tJ(b~ _L.te~~~~_~~~~L, tl ~S-R..1!:~7b LuMP. ijrU-$ \ \.,9.,""
L IlJ-iJ( '. W (Ii,'v, 4/0.11
ZIP
, d-- S3.J
t r'5't( 0
Page I 012
11111111111111111 111111111111 .-J
r SCHEDULE 7 TYPES OF GAMES --,
List all of the single types of games to be conducted at all license periods enumerated in Schedule 5.
Note for Vee:8S Niehts 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.
LIST NAME OF EACH TYPE OF
GAME OF CHANCE
(Umit: 5 Games)
fjl~ c Ie. Tit ( "-
:To t- f Il Ib t./f It..
lJ, ~ Sr~ W#ft!L
LIST THE MAXIMUM AMOUNT OF PRIZES
TO BE AWARDED FOR EACH TYPE OF
GAME OF CHANCE (GAME BANK)
at $ 500.00
at $ ,~-oo. 00
at $ .5"00. 00
at $
at $
For Merchandise Wheels, Bell Jars and Raffles, please complete the appropriate spaces below.
MERCHANDISE WHEELS:
INDICATE NUMBER OF
MERCHANDISE WHEELS
(NO LIMIT)
THE TOTAL AMOUNT OF PRIZES FOR
EACH MERCHANDISE WHEEL SHALL
NOT EXCEED $10,000 AND NO SINGLE
PRIZE SHALL EXCEED $250
BELL JAR:
INDICATE IF THIS APPLICA nON
IS FOR A BELL JAR
LICENSE
YESD 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
YESO NO ~
IF YES, LIST RAFFLE DATES, TlME(S)
OF DRA WING(S) AND PRIZES IN
SCHEDULE 5
THE TOTAL AMOUNT OF PRIZES FOR
ALL THE RAFFLES CONDUCfED DUR-
ING THIS CALENDAR YEAR SHALL
NOT EXCEED $100,000. NO SINGLE
PRIZE SHALL EXCEED $50,000
EXCEPT THA T A SINGLE PRIZE OF
$100,000 MAY BE AWARDED IF SO
INDICATED IN SCHEDULE 5
L BJ-GC-2B (Rev. 4103)
Page 2 of2
111111 III 11111111111 1111I ..J
r:;~~. '
"""p
< C'*'K SIMON KAUFMAN
ERNA KAUFMAN
9 SOUTH VIEW LANE
i HOPEWELLJUNCTION, NY 12533
-
~")~
216CP
[)"i"~ ok
$ 9J trr-~
50-235/219
561
to the
of
6) ContainsSacurlty
JD lTI Features., Delalls
O,l,,-:n.:IrS I on Back
For ~
, ~~~~
II. 0 2 7.... . 0 :U; 5 ....11. 2. b 0
l(:'CHECK GALLERY, 1995 STYLE # P03 1-800-354-3540 www.checkgallery.com
PRINTED ON RECYCLED PAPER USING VEGETABLE-BASED INKS
TOWN CLERK
TOWN OF WAPPINGER
20 MIDDLEBUSH ROAD J
/ \yAPPIN9,RS FALLS, NE~ YORK 12590 DATE ~I A't'../lJ 6-
( t-;.rr<--' 15 + ~) /J
~ECEIV~~~ROM /.I~~/~~7" sI;<tc2 $I.w I~
T~/!' .' ,_ /~'" , DOLLARS
FOR ? {l (J-et!A..J ~) /tj' ~t _ ~L.; /~/t' (,
O / . ' crhankC;You
CASH j ~1 il ..
[B'CHECK BY , I) ~
o M.O. .
09657
AMOUNT OF ACCOUNT
BALANCE DUE
-
50-235/219 CJ ')
561 216 au
[)I,{"~ ok
$ 9J II-r'-~
'~(l
(> (f"'~K SIMON KAUFMAN
ERNA KAUFMAN
9 SOUTH VIEW LANE
i HOPEWELL JUNCTION, NY 12533
]PiIlY to iill"
01'dm' of
[)ollRiIlll's {II
Contains Security
Features. Details
on Back
~
Foll' ___
I:02.g02~
At'
III 0 2 7... . 0 ~ b 5 ... III
@CHECK GALLERY, 1995 STYLE # P03 1-800-354-3540 www.checkgallery.com
PRINTED ON RECYCLED PAPER USING VEGETABLE-BASED INKS
TOWN CLERK 0 9 6 5 7
TOWN OF WAPPINGER
20 MIDDLEBUSH ROAD /
/ \yAPPIN~JRS FALLS, NE~ YORK 12590 DATE }j ~l' Ii) "
(.~rrf- /5 A~~J C' ? -sf ' I ~
/ #'; ,,I '''7/ /\ (j r:.,-O t")J?,
RECEf~U~~"~~-I'- M"L $DO~
FOR" P (i (JU~~) /tl/t;frt ~~ /,113ft"
/ I ' . / crhankC;You
D ?ASH j t/. rJ ..
[M'CHECK BY , ~,;""J~
D M,O, .
AMOUNT OF ACCOUNT
THIS PA
BALANCE DUE
r'
GC-2
--,
NYS RAC1NG & WAGERING BOARD
) Walervliel Ave. Ex!.. Suilt: 2
Albany. NY 12206-1668
Telephone C\ 18) 453-8460 Fax (518) 453-8492
www.racing.stale.ny.us
APPLICATION )?OR:
PLEASE CHECK
GAMES OF CHANCE 0
BELL JAR 0
RAFFLE 0
FOR OFFICE
USE ONLY
$\ I [I]/ITJ/ITJ
Fees Received Dale
INSTRUCTIONS: PLEASE FILE THREE SIGNED COPIES WITH MUNICIPALITY
GC- [ITIJ- 0011]- ~- ~
N.Y.S. Idenlificalion Number
IT IS A MISDEMEANOR TO MAKE ANY FALSE STATEMENTS IN THIS APPLICATION
lDW ~ c9 ~ wA-~P\ tJ~R '\)vTC~r!5 '-;,
Name of Municipality County
2. Address
3. Has applicant ever been denied a games of chance license? 0 Yes
4. Check lype of organization and. if applicable, give the Stale and date of incorporation.
Corporation 0
Stale incorporated V r7.Lu "Afl V
Incorporated Association ~ - "\,.Y.K- -
Unincorporated Association 0
State incorporated ".. .
Date~ / rMJ] / ~
Date 0] /0] / IT]
5. Did your corporate status change since your identification nu,ber was assigned? 0 Yes ~o
Indi vidual
o
6. Are you uoing business under a trade lIame? 0 Yes 0 No If "yes", what is the trade name?
PART B. LOCATION OF GAMES
7. Address where games. bell jar. or raffle drawing(s) are 10 be conducted.
{ { <?S-- ~. ~~ wt\Pf, A}~ f.J ,,\
I
8. Name and address of authorized games of \J l A
chance lessor renting to applicant.
9. Does the applicant own the premises? ~ es 0 No If "yes", how long'!
] O. Capacity for public assembly of premises presently owned or occupied.
It. 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?~Yes
Rrv&-.. 'cJ 4 \. )-(JO ~
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?
o No If "yes", give full details.
If "yes", Slate the type of license and number.
c:L....,. ooO,t-{....J-4 ~
13. Has such license ever bet:n If "yes", why? (Explain on a separate sheet, if necessary, and attach.)
revoked or suspended? 0 Yes ~o
L 8J-GC-2 (Key. 4/03)
Page lof2
11111111I111111111I1111111111 ~
r-'
I
PARI' C. PU1U'OSES OF l;AI\'ll~S
1'1 .'it:II,\! 1111' Spr'L;PtlJ'C..)MR~Irf.lll~1 pIlH.:l:t:ds ,Ut l\llJ~i
I S",C'(Jj \\11 .&lllI'llll
1'11~1 :\I..l. :!I~ ;Jlluclicd .'H'II<.:lIull~S an: i1ll1<llt'.riilll)(lIlll~H:"1' IIlld illl: incorpolill<.:d 11t:ICill iI~ if s<.:lullllll full illllic: upplicilllUl1. Alllhc: umw..../'.'
""l\i~lll"d III .his ilpplic\'IJUII un: illIJiu<.:ri,1l pw I ht:rc:ul.
I hullllC: <':111111..' 11<':1 iJ1vCI'''IJ.:, vi ull gUIlIC::i of dllUICC shull be: JCYUlcJ c:x<.:I\lsiycl)' tu one: Ill' Illore DI' the "Iawful purposes" ~s llelineo in 1I1C G,IIllt'S ui'
ChUlle!; UI'!;II,ing LaW ",nJ Ille: kllles iHld Kc:gululiolls 01' Ihe: H'lUrd.
J. lh~l lOr c'Jl'Illl,:eIlSt: pc:ri...J tor wlli,'1i illic':/hC i.\ sOllglll, nile III 111\11',. oj' lilt: u,liv<.: IlIclllb..rs 1II1Jt:J WIHlSC slIpcryisiolllllc gallu:s llre to bc hell!.
"\>erill"J illIJ cVIIJuCI.:J, whu is tUllulillr wilh Ihe: GUIIlC:S of ChillKC: L.i....c:llsing Law, Iht: Kllles am.! Regulations or Ihe N. Y.S. RaclI1g & Wll!!enllg
dUUld 'lIlJ j,xallicellSillj; vldillilll':C.; ')lla\\l.\. Will be PI":~Sl~1l1 ill .tlllhllCS, illchargc: alld pzimUlily le~l'ollsilllc fllr UH:. COIH.lIICI of games.
4. II/ill lil, 1I11lkrsIglleJ WII! Il<' rl'spulIsibk rill lhe linldillg, opc::rUlillll allU CllllUlI.:1 of ull gllll\<:~ uf .:Ilwlcl: ill U';Cill'Ulllll:e wilh lhe lCUllS of lhc Iicellse,
,ill: f;J ", ,.,i,m, \11 '.h.: (.;.\,II\I.:S vI' Chilli':" LiCCII.>lII!( 1.lIw. lile Rules ill1i1 R<:glllulitJns or lhe N. YS. HucllIg ,\:( Wagcring ~oard and WIlh tile pnlYIslDIIS
,)[ i",',J. Il.:enslllg OIUIIIJII,'<.'S \.II JdWS.
'. Ttlal IIIC ullu,rslgll,d liils reaJ and IS (ulIlIl",r Wllh lilt: [If<lvisillllS Dr lite C;aIIIIlS lIrCltalH;C Li<':C:IISlllg LiW liS WIlCllucd, thc Knies una Rcgul'IIIUIIS
"I 1I1~ ~,) S I~ilcill~ & ", ai/.cnn~ Bllunl, U1\(J lhl~ 1,lcul Jicc:nsillg onhllilllccS or laws.
(l. ThUll'" "'.IIIII1IlS,IIJI\, 'diM)', COlllpt:IIS111I\Jn, rewurd or rccompense willl1tl paiu III any pcrsoll for holdlllg Ulllssisling III tllc opt'rULJllg or
",'IIJUdIlIE "I' 1I1~ guII...S, c.\c"Vlltl bll,,~k(..I~I'L'r, m ilCClllllllilllls rDI' 11Illlcssilllllll scn'i....cs illllJl <t11101l11111lJl c.......ecdillg thili thed by llle Bourll.
".
/
'..') , /'
....;::... I . .. &.. '-.-
. c': ( :t,tf -C. " ~.l,.,' u v ~ "./.......
._......___''''-_.;...A__..L.. ___.__.___...__"_
Sig'II~lllln(o ,)1' H':i1d or Ul'gH1lIl.illiOIl
/)
I~' /,,-,1 <!. ; "-
Prilll NJII1~
s
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,
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[Q1Tj / If]i.J / lQT&]'
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/\t.~< / r- 5- 6 ./...
'i I .\11::
O!.
NEW YORK
l'tJUNTY
OF
~~ss
"/'
}ss
('ITY r[OWN.'\'ILL:\UL
U!.;
...i
f.ct;v(c.::.:LH ~; K LJ L. rS'~i..'._ b....illg duly sworn dt\pos~s Jill! says thai (S)ll~ is th~ p~rs<'>1\ abOVe IHUlled.
if::';II'~:'G,~il:;-~~';;Jlfi~ rur>.:~:~;;g ,;tl~;[';I;iJiht; i1IIS\\'t:"lll.:,~ill IllJlt:d. IlIld lhlll sud! UIISWI;:J'S an.~ Ifllt: IlIlU thul (s)he IJUs personally
,i1II\,,.; IllS (!l"", ,lgll"lLln.::u tillS allidilvIL
. I <I-L.. . II j
:>1'o"llll\.l Il~I.'I': 111<: l!liS_._~___ d;.l)' ,'I '~vr:,'
_.--.::.~~ ----.T L)c l-d bl ',0 __" 'J
1\01;11) 1'1I111ic:
20 v G-
.',
" A. 'n
S i g lIl~d ;>4J../.Jl52-
(
\ . '.- i ~) I ,
. ~':::s/'vv' (.. \.I'"
COlllmissiOll,~r or D.:cds
:',1) C"'J:I\llIis~;,111 ,.,\piIL'S __.
I ,
vJ3.~.__ J...!__, 2U ~
'v )
SARA J. DOBBINS
Notary Public. State of New York
Qualified in Dutchess County
Commission No. 01004865746
Commission Expires July 21;)J' J ~
L t1J.(,t'." 11<.... ~,UJJ
[.Iilgc '2 \)1 2
111I11111~111l1II1I11111I111 .J
r
GC-2A
-,
NYS RACING & WAGERING BOARD
I Watervliet Ave. Ext., Sujte 2 .
Albany, NY 12206-1668
Telephone (518) 453.8460 Fax (518) 453-8492
www.racing.state.ny.us
APPLICATION FOR GAMES OF CHANCE LICENSE
f P \
Name of Organization
GC- rn - [JIill] - [ffiU] - [QJlli]illJ
NYS Identification Number
SCHEDULE 1: OFFICERS AND DIRECTORS
US( namc:s, addresses and dales of blnh of all officers.
If organizalion is a corporation. or an incorporated or unincorporated association, list officers and directors.
TITLE NAME..,-,\, II./Z. .... DATE Q{ BIRTH STREET ADDRESS CITY
IC~1!~ trH,.-~I~1--LI _I 1
, 1_1_1_1 I
I 1_1_1_1 I
, 1_1_1_1 I
I 1_1_1_1 I
I 1_1_1_1 I
I 1_1_1_1 I
I 1_1_1_1 I
I 1_1_1_1 I
I 1_1_1_' I
, I_/~L.__I I
Attach additional 'sheet if necessary.
MEMBERS IN Cm.RGE OF GAMES
(MUST LIST AT LEAST FOUR MEMBERS OF APPLICANT ORGANIZATION)
DATE YEARS OF
NAME OF BIRTH MEMBERSHIP STREET ADDRESS CITY ZIP
?Q.v L- "1f0l~-.:i 1 l:Q. 1 "S-I---LL I. \;L( AJJl)R~~ RO j ~pt.t', wtz.z 'J-S 41>
\(\Lt~ f)o~P>\v1 5"' 1 ~I ~I~I fa ~ ~V1j~ GR/ I~()f -~ 1 t~&"1l?
~l\..{OV l<~~ '61 ~I .1z.Q.1~J ~ So\!T1t- v'l~lJJ UJ ,~~~..1"~, I \~~; ~
l-.~ tal~\ V\ '~/..n../ \fC; I 3 I)..~ ~lM~ ~U! "* ~r? .\fk/L~ 1).~--q'O
. 1 1 1 I I I I
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Date
ZIP
SCHEDULE 2:
SCHEDULE 3: AUXILIARY/AFFILIATE ORGANIZATIONS ASSISTING AT GAMES
(MAXIMUM OF 2 AUXILIARIES/AFFILIATES. BACH AUXILIARY/AFFILIATE LISTED MUST HAVE ITS OWN ID NUMBER.)
L Bl~::~:J:U~Y/AFFll1A1E G::f~F CHANCE ill NUMBER 1IIIIIIIIm~lIlllmll~l~ -.J
r SCHEDULE 4: ASSISTANTS TO MEMBERS IN CHARGE OF GAMES I
Lisl all members of applicant organizalion and members of authorized affiliales and auxiliary who will aSSIst with games. Each person listed must be a
member of appliclUll or~aniZlltjon or affiliate for alleusr I year.
YEARS OF
MEMBER NAME . DATE OF BIRTH MEMBERSHIP STREET ADDRESS
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L lU.GC.2A (Kev. 4/03)
Attach additional sheet if necessary.
Page 2 of 2
CITY ZIP
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Schedule 1: Officers and Directors
WAPPINGER LODGE #2609 OFFICERS for 2005-2006
Title Name Address Town Zip DOB
Exalted Ruler Steve Orobnak 53 Moccasin VieW Rd. Fishkill 12524 02/02/1957
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 09/1511957
Chaplain Diana M. Cole P.O. Box 549 Hughsonville 12537 0412511948
Inner Guard Rosemarie Perretta 35 Cathy Road Poughkeepsie 12603 09/07/1943
Secretary Robert M. Acquanita 10 Vorndran Or. Wappinger Falls 12590 0512511942
Treasurer Richard O. Oesruisseau 183 Red Cardinal Court Poughkeepsie 12603 11/0511936
Tiler Jacqueline Alfano 93 Brothers Rd. Wappinger Falls 12590 08127/1938
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 05102/1942
Trustee louis Antolotti 229 Robinson Lane Wappinger Falls 12590 06123/1933
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 O.
Richard D.
Stephen F.
Robert
Mark H.
Harris C.
Robert J.
Joseph
WilliamK
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
Ju~ano .
Jurina
Minkowski PSVP
Pampa lone
Perretta
Sarno
Tucker
Wallner
DaB Address
04/24/1940 39 Kensington Drive
05/16/1937 6 Haekensack Hghts Rd
12/21/1935 12 Thorns Lane
01/11/193628GoldRoad
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
~
I
GC -2B APPLICATION FOR GAMES OF
NYS KAClNU& WACiEKINCi"BOAIW CHANCE LICENSE
I Watc:rvlit:l Avt:, EXl:, Slllle 2
Alhany, NY 122()o"IM8
Tt:lt:phuno: (51 H) 453-S4bO Fax (51 ll) 45.\ ~W>:2
www.rllcillg.slale.ny.l1..
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GC- [illJ- [J[LliJ -1~lol~l- ~
NYS Identiticalion Number
I ~1-91 / [iliJ / I or~l
Date
SCHEDULE 5 DATES, HOURS AND RENT OF ALL LICENSE PERIODS TO BE HIi:LD
(NOT APPLICABLE FOR BELL JAR GAMES)
DATE . HOURS
JQ / ~/ [) ~ ,:~r~OOm/@)- ~~:, 6,O~@pm is,
o t ( / 0 ':?/ :Qk: : o'7'..~mll /@- l : t) 0 0 @PlIl ! $ 0
o / 0 / ~_________ . 0 ,um / pm ' , . . , am / pm i $ 0
/ ______ / am / pm .. : ~~ am / pm i $ .
. /. . 0 / o. .. . .am / pm - am / pm I $
~_~ / ,.__~~ / ._._~: ~.__~.__..: ~_._----,am / pm - ,', am / pm ! $ ,
/ / I .mn / pill - am / pm i $ ~ '
. /. . / '---'"-~ .am / pm - am / pm I $
. / ~~.~ / ___~_..~ . ~~--' am / pm - , . . ,am / pm i $ ,
l / _~..~~aIll/pll1 ,,' am/pm i$~
. / / .am / pm~J. ' ,.. .am / pm I $ 0
I / _______~.~~am/pm - .:~_am/pm 1$
RENT
. 0
.~~
---..I . \---""'""'---'
RAFFLES
. I '--_ __ _---.4 . ...
PRIZES (Cash or Fair Markel
Value of Merchandise)
!$,
!$.
!$.
i$__ '
:$
DATE
TIME
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SCHEDULE 6 EXPENSES
List items of expense to be incurred, and the names and addresses of persons to be paid.
lTEM OF EXPENSE VENDOR NAME STREET ADDRESS CITY STATE
c.t.tmJl116- rz" ~~~L..~:3Cr-11o~'
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ZIP
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Page I 01 2
1111111111111111111111111111 -1
- r SCHEDULE 7 TYPES OF GAMES --,
List all of the single types of games to be conducted at all license periods enumerated in Schedule 5.
Note for Ve2aS Ni2hts 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 $500 for each single type of games of chance when less than five single types of games of
chance are to be conducted during anyone license period.
LIST NAME OF EACH TYPE OF
GAME OF CHANCE
(Limit: 5 Games)
fJ LA' Ie.. :::r /} ( k..
::To t.. f Il.. Ib ill Il..
/J) ($ Sl'~ wi/($L
LIST THE MAXIMUM AMOUNT OF PRIZES
TO BE AWARDED FOR EACH TYPE OF
GAME OF CHANCE (GAME BAN~()
at $ So 0 . 0 ()
at $ ,1-00. 00
at $ .5"00. 00
at $
at $
For Merchandise Wheels, Bell Jars and Raffles, please complete the appropriate spaces below.
MERCHANDISE WHEELS:
INDICATE NUMBER OF
MERCHANDISE WHEELS
(NO LIMIT)
TIlE 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 APPLICATION
IS FOR A BELL JAR
LICENSE
YESD NO ~
TIlE 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 t!-
IF YES, LIST RAFFLE DATES, TlME(S)
OF DRAWING(S) AND PRIZES IN
SCHEDULE 5
THE TOTAL AMOUNT OF PRIZES FOR
ALL THE RAFFLES CONDUCfED 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
INDICA TED IN SCHEDULE 5
L BJ-GC-2B (Rev. 41(3)
Page 2 of2
11"'"11 "'" " /lUIIII ..J
I
GC-5
I
LICENSE TO CONDUCT
GAMES OF CHANCE
PLEASE CHECK
GAMES OF CHANCE ~
BELL JAR 0
RAFFLE 0
GC - [ili] - ~- ~ - C2IiliIlli]
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 50.00 II I
Amount of Fee Paid Lessor's License Number
Address: 1195 Rt. 376 City: Wapp i ngers Fa 115
Entire net proceeds to be devoted to the following specific lawful purpose(s):
Zip Code: 12590
1/3 Charitable
Names of Members in Charge
Paul Bader
2/3 Operations
Rich Dobb i ns
Simon Kaufman
Lew Hakim
LICENSE PERIOD
DATE
10/06/2006
11/03/2006
DAY OF WEEK
flOURS
TYPE(S) OF GAMES
Friday
Friday
7:00pm - 1:00am
7:00pm - 1:00am
Blackiack. Joker Poker. Biq Six
Blackjack, Joker Poker, Big Six
RAFFLE DRAWING
DATE
DRAWING TIME
DRAWING LOCATION
AMOUNT OF RAFFLE PRIZES (Cas~ or Merchandise Prizes
at FlIlr 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
$
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)
cr/JO!OCo
(Date)
TOWN CLERK
Title of Authorized Officer)
;~
uthorized Officer)
11111111111111111111111111111 .J
L BJ-GC-5 (Rev. 4/03)