Wappinger Elks Lodge
I
GC-5
NYS RACING & WAGERING BOARD
1 Broadway Center, Suite 600
Schenectady, NY 12305-2553
Telephone (518) 395-5400 Fax (518) 347-1469
www.racing.state.ny.us
"I
GC - [l]l] - GIiJiJ- [iliLJ-
N.Y.S. Identification Number
LICENSE TO CONDUCT
GAMES OF CHANCE
PLEASE CHECK
GAMES OF CHANCE ex
BELL JAR 0
RAFFLE 0
ITlQILG]
,f.~".
"'I~Il" ~
", I
fi c,;'
C'
This License Must Be
Conspicuously Displayed
During Conduct of Games
$1 25.00 II
Amount of Fee Paid Lessor's License Number
Municipal License Number
The following organization:
Address: CIty
11 q') Rnllrp i7fi . : WRppingers
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
Falls. NY
Zip Code: 12590
Rirn Dnnnins
Simon Kaufman
Lew Hakim
LICENSE PERIOD
DATE
5/2/2008
DAY OF WEEK
Friday
HOURS
7:00 PM - 12:00 AM
TYPE(S) OF GAMES BHx
Black Jack, Joker Poke~ Wheel
RAFFLE DRAWING
DATE
DRAWING TIME
DRAWING LOCATION
AMOUNT OF RAFFLE PRIZES (Cash or Merchandise Prizes
at FaIr Market Value)
THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
FOR EACH MERCHANDISE WHEEL
$
THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
FOR EACH TYPE OF GAME OF CHANCE
1 $ 500.00
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
ST A TE LAWS AND RULES AND LOCAL ORDINANCES OR
LAWS.
(Date)
Issued by
TQWR of W~rFingPT
(Name of Municipality)
4/14/2008
L BJ-GC-S (Re\'. 3/06)
'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.raeing.state.ny.us
I
FINDINGS AND
DETERMINATION
FOR GAMES OF CHANCE
LICENSE
GC - m - GJDJ - GIQLJ - CillIQILGJ
N.Y.S. Identification Number
Dutchess
County
After investigation, and a hearing if required under Sec. 192 o~e General Municipal Law, the following findings and determinations
have been made: ./ /
1. Allth' m,mb,,,;-in-ch"" d"ign",d iot" npo.' '. .:/. nd gam of ch.."." of good mom! My" 0 No
character and have never been convicted of a i " .
Town of Wappinger
Name of Municipality
.1195 Route ~76. W::Ippjngprc:: li'",11~) N9W York l?')Qn
Address
Signature of Person Conducting Investigation
s h~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)
GQ Yes DNo
~Yes DNo
KJ Yes DNo
10 Yes DNo
Kl Yes DNo
Kl Yes DNo
Kl Yes DNa
KJ Yes DNa
DYes DNa
TO BE COMPLETED BY MUNICIPAL CLERK: /
As a result of the findings and determinations stated above, license is GRANTED rn(license is DENIED 0
~ Signature of
Filing date af Application Ot" Authorized Officer
~~Dt
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.
Title
Tm.:m C.l prk
Date
L BJ-GC-4 (Rev. 4/03)
1\111111111\11111111\1 1111\1\ .-J
TOWN OF WAPPINGER
TOWN CLERK
CHRIS MASTERSON
SUPERVISOR
CHRISTOPHER J. COLSEY
TOWN CLERK'S OFFICE
20 MIDDLEBUSH ROAD
WAPPINGERS FALLS, NY 12590
(845) 297-5771
FAX: (845) 298-1478
TOWN COUNCIL
WILLIAM H. BEALE
VINCENT BETTINA
MAUREEN McCARTHY
JOSEPH P. PAOLONI
April 14th, 2008
Wappingers Elks #2609
1195 Route 376
Wappingers Falls, NY 12590
Dear Kaufman:
Please find the attached "License to Conduct Games of Chance" for
your Casino Night to be held on May 2nd, 2008. I have also attached a receipt
for your payment.
Please do not hesitate to contact my office with any further questions
or concerns.
Sincerely,
J hn C. Masterson
Town Clerk
J CM/dm
TOWN OF WAPPINGER
TOWN CLERK
CHRIS MASTERSON
SUPERVISOR
CHRISTOPHER J. COlSEY
TOWN COUNCIL
WilLIAM H. BEALE
VINCENT BETTINA
MAUREEN McCARTHY
JOSEPH P. PAOlONI
TOWN CLERK'S OFFICE
20 MIDDlEBUSH ROAD
WAPPINGERS FAllS, NY 12590
(845) 297-5771
FAX: (845) 298-1478
April 14, 2008
New York State Racing and Wagering Board
1 Broadway Center, Suite 600
Schenectady, New York 12305-2553
Subject:
Games of Chance License - Wappinger Elks #2609
Please find enclosed the GC-2, GC-2A, GC-2B, GC-4, GC-5, GC-6 and GC-2B for
the 'Wappinger Elks #2609 Casino Night to be held on May 2nd, 2008.
TOWN OF WAPPINGER
TOWN CLERK
CHRIS MASTERSON
SUPERVISOR
CHRISTOPHER J. COlSEY
TOWN COUNCIL
WilLIAM H. BEALE
VINCENT BETTINA
MAUREEN McCARTHY
JOSEPH P PAOlONI
TOWN CLERK'S OFFICE
20 MIDDlEBUSH ROAD
WAPPINGERS FALLS, NY 12590
(845) 297-5771
FAX (845) 298-1478
April 3, 2008
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,
Located at 1195, Route 376, Wappingers Falls, NY, who will be conducting Games of Chance
on May 2nd, 2008.
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.
Sincerely,
Q(:v1k-
~ )
J~ C. Masterson
T own Clerk
Enc.
-,
r
GC-2
NYS RACING & WAGERING BOARD
I Broadway Center, Suite 600
Schenectady, NY 12305-2553
Telephone (518) 395-5400 Fax (518) 347-1469
www.racing.state.ny.us
APPLICATION FOR:
PLEASE CHECK . /
GAMES OF CHANCE ~
(Casino Nights, Bazaars, Carnivals)
BELL JAR 0
RAFFLE 0
(only raffies wi over $30,000 net profits in calendar year)
.,,~
~1. · " /];'; ~
,-. .
~ ';'~ ,- \~.u ...,."/,~" ~
__. ___ ,__ ,__..__' ,____ ______._____ ...n_____.. ___u_ u__
1t1 [fll ~ 1\0 1 pi
Date
--I
,
I
FOR OFFICE
USE ONLY
_____._____._________'___ _n ..._,___._~,._..___ ---_.-
$[ A5,t) U 1
Fees Received
INSTRUCTIONS: PLEASE FILE THREE SIGNED COPIES WITH MUNICIPALITY
GC- [illJ- QIII1l- ~- ~
N.Y.S. Identification Number
IT IS A MISDEMEANOR TO MAKE ANY FALSE STATEMENTS IN THIS APPLICATION
LUt}.(1) t V (:-~ R
'Ie w tJ () P--
Name of Municipality
'Di.rrct+~s S
County
2.
3. Has applicant ever been denied a games of chance license?
If "yes", why? (Attach extra sheet if necessary)
4. Check type of organization and, if applicable, give the State and date of incorporation.
Corporation 0
n:... State incorporated \J (!..\J i, ~ t'L~
Incorporated Association i - -. -
Date [ill] I call I [ill]
Date IT] I IT] I IT]
Unincorporated Association 0
State incorporated
Individual
o
5. Did your corporate status change since your identification number was assigned? 0 Yes !2f:t:.o
6. Are you doing business under a trade name? 0 Yes 'tz(No If "yes", what is the trade name?
PART B. LOCATION OF GAMES
7. Address where games, bell jar, or raft1e drawing(s) are to be conducted, Ll q;- lCl ,~ '/ (;,
UJt\e f, (Z-f}vLS ~--J\.,
(
8. Name and address of authorized games of
chance lessor renting to applicant.
9. Does the applicant own the premises? rJy~s
I'
VbPr
10. C.,,"";1> fo, pubHc _mbly of prem;"" pre,ontly ownod 0' occup;ed. :J.-8 (0
11. Have premises been regularly used? ~ es 0 No If "yes", how long? :d- 0 'f tZ-.l\-t../S?
Are games of chance being played now on these premises or has it ever been? Qt..y es 0 No If "yes", give full details.
Q-U C- . ',}-b 0 '1
o No If"yes", how long?
12. Are the premises or any part thereof
where games of chance are to be played
licensed by the State Liquor Authority?
"tfyes 0 No
If "yes", state the type oflicense and number.
C:~- bO 01 L{ ---.J.Lf ~
13. Has such license ever been 'r>d If "yes", why? (Explain on a separate sheet, if necessary, and attach.)
revoked or suspended? 0 Yes l,Ct 1::10
L BJ-GC-2 (Rev. 3/06)
Page 1 of2
III111111I 1111111111111 .J
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nl~1 ;,u.. ~II~ :.lll,IClied Svilellldl:s are a 1Ililll'.ri'll PHlllle-lel.i" Hlld 'Ill' ill~mfll)jaled IlelClI1 ilS ii" set uul III full illlile i.lppli~allulI. All the: al\SWl'rs
",II\i.IIII,,1111 ,liis i1pplil"llJllll ilrl'. i1l1liilerlill pUJ lll!.:reul.
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Ch~lI,c Ljl'clI,i118 L"w :;.IIJ llle kLlks ,\tIll Kegulaliuns or lhe HIlard.
lJ1~1 lur t'~d\ il,:eil,l' pc:ril.>d lor willeh lllkl~.nsc is suughl, \lIlt: III IlIure ur Ihl; U..ll,'!.: IIIClllbcrs uUllul wll<)se: supervisi()llllie: gUllu::s ure lU be: hell!.
l)~riHl'L.l "IIJ l'VIIJu.,:leu. wllU is tumiliur wilh Ihe GUII\!.:s or C1HuKC Liccllsing Law, Ihe 1{1I1es UIIU Kcgulutions ot the N, Y ,So Ral:ing /I< WU8e:nllg
",lUld ill'J lJ...ll1ce:IISilll; Uldlll:IIlC":, llr lillYs. willi\('. PI\'Sl'.1I1 a\ .lillilllr.:S. illl'i1u1llc Jlld plilll<lIily rcsl'ullsill1c kll'lhe: ..omhll'l of gumes.
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')1 i,',.... 1i<.e:Il,IIIj\ III 1.11 II.III(<'S ur l"w,.
, Ill~1 \lie LllIl.1nsl:;!1cd I\',IS reaJ unLlls iUlIlIliHr WIlh llle pnl"isil)llS Ill' the Cialll<;:s ill' Cil.II\;C Li,cllSlllg Law \IS ,UIlClILlcd. tile \{lIks illld Regll!\lliulIs
"I 1I1~ ~; \ .s I~U,III~ l~ \\ alJ.,nng. l3u,lrLl, \l1\L] tllc Illculli~I;II:;1J\g 11ldlllllll';CS ollllws.
(I. Thnl I,., ,',)111'"1",,)1\, SuIMY. ClllIlPI;:IISUllIJlI. ICwllru or rc:<.:Ulllpe:nse willllc fl(\io III any per~Lln for holtlilll:l UI assisting 111 tile: uperuting or
,','IIJudlllg e\f till' ~UII"'S, C.U'cpllll bililkk(o.l~pl'.rs nr "~I',()lIll1i1lltS rUr plllkssillllUI services ill all UlIll)UIllIIUl exceedillg tllUllhed by the Board.
\ol}) I [ill] I @J~~~-~~- /fta:LJ V/Jt..€7V!E
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.tlll\"'; I".s (Ilell st:;l\<.IlUl'o.: ~lJ tillS "llidaYI1.
CUl.'NTY
( IF
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('ITY!' lUW I\,'\' lL.L.\UI.
S"'''II\LIlI)':''lelll'llil~ _:?.~ llilYl'1 I~' 2()~
_.__?AfiI+ :J: abb/JJS
l\ut;'I) 1'1I1l1i"
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Sigmod />1v~ {;--t-r....
"
Commission~~r llf D..:cds
"-h (.'II:I\I\I1SS;,II\ c,\piICS __.
c.' 3
<) - _,_()____~ (') I <fu-- ___
SAHA oJ UUbDIi'i::'
Notary Public, State of New YOH(
Qualified in Dutchess County
Certified in Westchester County
Commission No. 01004865746
Commission Expires ..It+W-9.+ ,r86-1 -- <.J
~.___ _, .,J. ) /.,
- .Y/:::L ~CT(j;' ()
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III \ 1m I~I \1 II m II 1\1 I\U\ -1
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GC-2A
NYS RACING & WAGERING BOARD
I WaterVliet Avr.. Ext.. Suite 2
AlbanY. NY 122()6.1668
Telepbone (518) 453-8460 Fax (518) 453-8492
www.n&ing.stlllC.ny.us
APPLICATION FOR GAMES OF CHANCE LICENSE
(> P \
Name of Organization
oc-lillJ - rnilll- [lliill- @JiliIilil
NYS Identification Number
SCHEDULE 1: OFFICERS AND DIRECTORS
US[ names. addTcSSC$ and daleS or blnh or all officers.
If OI'PIlizalion is . corpontion. or an incorporatc4 or unincotpOBtc4 associalion. list officers and directors.
TITLE NAME~ DATIj Q{' BI}l.TH STREET ADDRESS
1 C ~~,(. /I'[ I'1Il\~T -LI _I 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
1 1_1_1_1 I
1 1_1_1_1 I
1 1_1_1_1 1
1 1_1_1_1 1
1 1_1_1_1 1
I I_I ~!:.~I 1
Attach additional sheet if necessary.
MEMBERS IN CHKRGE OF 'GAMES
(MUST LIST AT LBAST fOUR MEMBBRS OF APPLICANT OROANIZATION)
DATE YEARS OF
NAME OFBIRTH MEMBERSHlP sTREET ADDRESS CITY ZIP
?fwL. ~~~/l:2-) ~'51---1J-\\~ ft.IJ~MJ~~IlJ4-: Its
~\ u+-- i;;Jo{J,fH vip ~ I :2Q I ~ 1..-i~LJ 1. ~ l/-VVl ~ Q l? 1...v1\-l'f. ~! I .. \;"
~l-{O" l~J/._lE) 7.,0\ ~I '1. ~ln;l- V\~'" u., l~, '1'~J \ 1-':':
t.-F.J.i.J \~.ftl~\V\ \ 'I I -L-r/ \.tC \ '2, 1.......1.9 (+;\\)....<..&.1 .~ t...1\o 1....."..A'li')H?./ \~JI.. t C,l.. j,\.-:-
_ . . i~/~I ~i ' (..L='>l!e.=~y"d'!LL' W'..Li--~
1_1_1_1 I 1 1
1_1_1_1 1 I !
1_1_1_1 I 1 I
1_1_1_1 I \ I
[QB]/@]/~
Date
CITY
ZiP
SCHEDULE 2:
s Cm'nm.F" A UX1UA RY! A l'F!LU TE ORGANlZA nONS ASSISTING AT GAMES
tH...xr?!;u~,', Dr 1 A;.'X IdA!" !FSi.A.FFlLLATI'.O:; EACH ...iJXILL"~'{'Ii.A.r1:'ILlATE USTED MUST }l..A.\IE IT::; O\VN If'> NUMn2R
GA.MES OF CHA.J~CE ID ~lJM3ER
L~:O:UXYiAFF~'~
page 1 of2 11118UI'I' -
"\-
..'.'.'...........'.'..........'." ,,'.
Sch'~clule 1, OfficE;
WAPPINGER LODe, r. t
Title
,.......,..........__.......__............... ...,..._ ,..",,,,_ ,'d", '.
NaIll"
Exalted Ruler
Leading Kgn
Loyal Kgn
Lect. Kgn
Esquire
Chaplain
Inner Guard
Secretary
Treasurer
Tiler
T rus tee
Trustee
Trustee
T rl.Jstee
Trustee
Haec;::!
Mark
Eil~..e'l
VaGa:lt
Anthn
Gath
Vaca:1.t
RobHt ;\11
Pam~a~.:: i::.
Susan
Jamf:~';
Salvi,:t(i~l'
Dane
Jose;:)i~ V':",
Vaca nt
No c.n~;!:
.1
1.,/ "
.;,j
H
/'1,' ::1.
M.ill~
ii('
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d
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1 i::~
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;;;
'i 2
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I' SCHEDULE 4: ASSISTANTS TO MEMBERS IN CHARGE OF GAMES I
LiS! ullmcmbcn Qf upplicuRt olgillliUltion and members of authorized affiliates and auxilillt)' who will asSist wilh lames. Each person IiSled musl be 8
member of uppliclIIlI orlllllliuuion or affiliate for III fCllSl I year.
YEARS OF
MEMBER NAME DATE OF BIRTH MEMBERSHIP STREET ADDRESS
I / / I_I
(~ 1=1=1= I _ I
_mEq) I 1 / I I
b-l'5r) '-/-1-' - I
1-/-/-'--1
1=1=1= I = I
I / / , I
1-/-/- I - I
'-/-/-1-'
,=/=/= I = I
I / / I I
1-/-/-1-'
1=1=1= I = I
I 1 / I I
'=1=1= I = I
I 1 / I I
'-1-/-/-1
__ - - _I
I 1 / I I
'-/-/-'-1"
1=/=/= I = i ~.
I / / I i
1=/=/= , = I
/ / ! I
___,_1
/ / i
i--- /-.-- /-- 1- j
1-/-/- I - .
i i I
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1/,
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/ I
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i
,
i
,
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L Bj.GC-L... (Key, ~iOJ)
Attach additional sheet If necessary.
CITY
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Schedule 4. Assistants to Members in Charge of Games
Years
First MI Last Name Address Town Elk DOB
Frank Abato 39 Kensington Drive Hopewell Jct 11 04/24/1940
Philip A. Abbate 6 Hackensack Hghts Rd Wappingers Falls 18 05/16/1937
Robert Acquanita 10 Vorndran Drive Wappingers Falls 22 OS/25/1942
Ralph J. Anzivina 12 Thorns Lane Highland 22 12/21/1935
Henry J. Boldrin 28 Gold Road Wappinger Falls 15 01/11/1936
Harold A. Crawford Sr. 318 Sunset Hill East Fishkill 18 02123/1936
Francis J. DeGano 27 Brandy Lane Wappingers Falls 18 07/18/1946
Roger DeJordy 83 Kent Road Wappingers Falls 18 09/19/1944
Robert Fischetti 91 Ardmore Drive Wappingers Falls 28 06/07/1926
Mark H. Fox 28 Tiger Road Hopewell Jct. 14 09/15/1957
Harris C. Jones 217 Brothers Road Stormville 18 04124/1944
Robert J. Juliano 2776 West Main Street Wappingers Falls 13 10/05/1953
William K. Minkowski 427 McGrath Blvd. Fishkill 28 03/20/1942
Rosemarie Perretta 35 Cathy Road poughkeepsie 8 09/07/1943
Gregory F. Sarno 13 Dana Place Wappingers Falls 28 07/01/1936
Kenneth J. Tucker 34 Pawling Lake Pawling 9
Robert N. Wallner 7 Kinry Road poughkeepsie 19 01/17/1933
-,
.
r
GC-2B
NYS RACING & WAGERING BOARD
1 Broadway Center, Suite 600
Schenectady, NY \2305-2553
Telephone (518) 395-5400 Fax (518) 347-1469
www.racing.state.ny.us
APPLICATION FOR GAMES OF
cHANCE LICENSE
L \). ff' \
Name of Organization
GC-Elli- Oft \qJ- [~\ O\1}-[!I'AoE \~
NYS Identification Number
SCHEDULE 5 DATES, HOURS AND BENT OF ALL LICENSE PERIODS TO BE HELD
(NOT APPLICABLE FOR BELL JAR GAMES)
D~E HOO~
P t{, .Q.2-1 .0 <61 ~ ": ~7C'l}m @ _ . ": .Q.AQ,@i)pm 1 L .
~, _ . .", ~I _ ,'_ _am/pm _ . ~'_ ~am/pm 1$_
) _ , ~, ~ . ) _ _ ' _ ~am 1 pm _ ~ ~' _ _am 1 pm I $ -
_ , ~, _' ,I _ _' . _am 1 pm _ _ ' ~' _ ~am I pm 1$ ·
.' _ .I _ . .1 _ j . _am 1 pm - ..' _ ,am 1 pm 1 $ -
" _ .' _ ) _ "'_ ~am/pm _ _'. .am/pm 1$_
. , _'. ",. "I _ .'_' _am/pm - ..'_ _am/pm I$~
"' _ " ,_ " 1 _ _' _ ,am 1 pm _ _ ~' ~ _am 1 pm I $ ·
. , , "' _ " 1 _ _ ' _ ,am 1 pm - _ h "am 1 pm 1 $ -
.I, _'.. ~I _ ",. "am/pm _ _ "'_ "am/pm 1$-
_' .I. . .I _' ,I _ ' ' . _am 1 pm - _ , " . _ ,am 1 pm 1 $ -
. _' _ . ,'_. .1 _ "'. .am Ipm _ ~'~ .am Ipm 1 $ ~
RAFFLES
DATE
\9\ ~11 ffi I \lill
Date
RENT
..--J . L--
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TIME PRIZES (Cash or Fair Market
1 Value of Merchandise)
~ ~ ~ : ~: T -::: ":11: >". ':;: !$$'-- . . . . ~',- . ~
, 1 .. - -'- - ! - , " ",-.,
. ' _'_ _,_ "'_ "am/pm _ _ ,'_ .om/pm !$- . ..'-
"' . .I. _! _ "'_ "am/pm - . .'. "am/pm !$. "'.
_' . .' _ ,I, _ .'. "am/pm - ~ _'_ ,am/pm !$- -'.'
S~H;EDULE 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
CLI~l!1 \J "" '7 (tItI-'l \\ e 1'11::>, \}-UttQ U if I \X> C)I\,U'of' lfc l'tJ C1 vi.
tA ClU \0 "'- l--ILll Vz~ e,v,'f1W. f) >-'fIt<) f\ \l~ .;.' l\f rF'.i-L-7 I-..i 'l-
ZIP
l )- .,.-77~
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\ _'" >L-/
L BJ-GC-IB (Rev. 3/06)
Page lof2
\1" ~I\" \ 1\ "I' \11\ .J
. .r-SCHEDULE7 TYPES OF GAMES I
Ust all of the single types of games to be conducted at a1Ilicense periods enumerated in Schedule 5.
Note lor Ve as Nt bts and Ba""ars onl : The total amount of pri.es 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 an: to be
conducted during anyone license period. The total amount of prius during anyone license period sball nol
aggregate more than $500 for each single type of gameS of chance when less than five single types of games of
chance are to be conducted during anyone license period.
UST NAME OF EACH TYPE OF
GAME OF CHANCE
(Umit: 5 Games)
Dl~ c /c. ~f} c k-
.:To I.- f t !o!-/ It
13/6 51'1- u#,lL
LIST THE MAXIMUM AMOUNT OF PRIZES
TO BE AWARDED FOR EACH TYPE OF
GAME OF cHANCE (QJ\ME BANK)
at $ So 0 , 00
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)
THE TOT AL AMOUNT OF pRIZES FOR
EACH MERCHANDISE WHEEL SHALL
NOT EXCEED $10,000 AND NO SINGLE
pRIZE SHALL EXCEED $250
BELL JAR:
INDICATE IF THIS APPLlCA TION
IS FOR A BELL JAR
LICENSE
YES 0 NO 'r:f.
RAFFLES :
INDICATE [F THIS APPLICATION
IS FOR A RAFFLE
LICENSE
YESO NO tf
IF YES, LIST RAFFLE DATES. TLME(S)
OF DRA WING(S) AND pRIZES IN
SCHEDULE 5
L BJ-CC-2B (Rev,~)
TIIE TOTAL AMOUNT OF PAYOUTS
FOR EACH BELL JAR DEAL SHALL NOT
EXCEED $3,000 AND NO SINGLE PRIZE
sHALL EXCEED $500
THE TOTAL AMOUNT OF PRIZES FOR
ALL THE RAFFLES CONDUcrED DUR-
ING THIS CALENDAR YEAR SHALL
NOT EXCEED $ \ 00,000. NO SINGLE
pRIZE SHALL EXCEED $50~
EXCEPT THAT A SINGLE PRIZE' OF
$100,000 MAY BE AWARDED IF SO
INDICATED IN SCHEDULE 5
p,..z of2 1111111111111I \ I 11\ ~II\