Wappingers Elks Lodge
r
GC~5
--,
LICENSE TO CONDUCT
GAMES OF CHANCE
PLEASE CHECK
GAMES OF CHANCE rn
BELL JAR 0
RAFFLE 0
GC - rn -lliG]- GJ:QLJ - GLLLIJ
N.Y.S, ldentification Number
NYS RACING & WAGERING BOARD
1 Broadway Center. Suite 600
Schenectady, NY 12305-2553
Telephone (5J8) 395-5400 Fax (518) 347-J469
www.racing.state.ny.us
This License Must Be
Conspicuously Displayed
During Conduct of Games
Municipal License Number
The following organization:
$1 ? ~ no II
Amount of Fee Paid Lessor's License Number
Address: 1195 Route 376. City: Wapp:lng~rR li'::tlh, NV
Entire net proceeds to be devoted to the following specific lawful purpose(s):
1/3 Charitable and 2/3 Operations
Names of Members in Charge
Paul Bader
Zip Code:
l?~Qn
Simon K'<l11fmS'ln
T.~T&7; Q J:I~lr.;m
Greg SRrnn
LlCENSE PERlOD
DATE
06/04/10
DAY OF WEEK
HOURS
TYPE(S) OF GAMES
7:00 pm- l?nn p~
Rl <>('lr T?d:
Jok~r Pokpr
Bi~ Six Whe~]
AMOUNT OF RAFFLE PRIZES (Cash or Merchandise Prizes
at fair Market Value)
RAFFLE DRAWING
DATE
DRAWING TTh1E DRAWING LOCATION
THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
FOR EACH TYPE OF GAME OF CHANCE
$
NUMBER OF GAMES EACH GAME (Stanmg Bank)
THE TOT AL 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 ~
ST A TE LA WS AND RULES AND LOCAL ORDINANCES OR
LAWS.
Issued by
Town of Wanpin~er
(Name of Municipality)
TnT.Tn (1.1 &;1,...lr
(Title of Authorized Officer)
(Signature of Authorized OffIcer)
\\\111\ 11111\\1\1\\ 11\ \ I~ \1\ .J
May 19, 2010
(Date)
L BJ-G~-5 (Re,', 3/06)
r
GC-4
NYS RACING & WAGERING BOARD
1 Watervliet Ave. Ext.. Suite 2
Albany, NY 12206-1668
Telephone (5 J 8) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
I
FINDINGS AND
DETERMINA TlON
FOR GAMES OF CHANCE
LICENSE
GC - Q] - [iIjI;J - ~ - GIiliILW
N.Y.S. Identification Number Municipal License Number
Name of Applicant Organization
1195 Route 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 determinations
have been made:
I. All the members-in-charge designated in the application to conduct games of chance are of good moral DYes D No
character and have never been convicted of a crime.
Signature of Person Conducting Investigation
Title
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 accordan~e with the
provisions of the Games of Chance Licensing Law.
9. If applicable, the rentlo be paid to an authorized games of chance lessor is reasonable.
10. Other findings: (Specify)
&I Yes DNo
iI Yes DNa
&I Yes DNa
IX! Yes DNa
IX! Yes DNo
IX! Yes DNa
IX! Yes DNo
IXI Yes DNo
DYes DNa
TO BE COMPLETED BY MUNICIPAL CLERK:
As a result of the findings and determinations stated above, license is GRANTED D; license is DENIED D
Signature of
Filing date of Application May 11, 2010 Authorized Officer
(Municipal Licensing Authority)
Date
Title Town r.l ~rk
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<;C. (lID. 4103) m Imm I a 111alllll M\ -3
... ~...
, r SCHEDULE 4: ASSIST ANTS TO MEMBERS IN CHARGE OF GAMES
List all members or applicant organization and members or authorized affiliates and auxiliary who will assist with games, Each person listed must be a
member of applicant organization or affiliate ror at least I year,
YEARS OF
(JMBER NAME DATE OF BIRTH MEMBERSH~ {TREET ADDRESS
~ 8 E:- It tr) 41 ~ IE~ l.-.J.:f. Y 7" I
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--- -
CITY
L BJ-GC-1A (Rev. 3106)
Attach additional sheet if necessary.
Page 2 of2
_111111111111 .J
--,
ZIP
Schedule 4. Assistants to Members in Charge of Games \
Years j
First MI Last Name Address Town Elk DOB
Frank Abato 39 Kensington Drive Hopewell Jet 11 0412411940
Philip A Abbate 6 Hackensack Hghts Rd Wapplngers Falls 18 05116/1937
Robert Acquanlta 10 Vorndran Drive Wapplngers Falls 22 OS/25/1942
Ralph J. Anzlvlna 12 Thorns Lane Highland 22 12121/19~5
Henry J. Boldrln 28 Gold Road Wappinger Falls 15 01/11/1936
Harold A. Crawford Sr. 318 Sunset Hili East Flshklll 18 02123/1936
Francis J. DeGano 27 Brandy Lane Wappingers Falls 18 07/18/1946
Roger DeJordy 83 Kent Road Wapplngers Falls 18 09/19/1944
Robert Fischetti 91 Ardmore Drive Wapplngers Falls 28. 06107/1926
Mark H. Fox 28 Tiger Road Hopewell Jet. 14 09/15/1957
Harris C. . Jones 217 Brothers Road Stormvllle 18 04/24/1944
Robert J. Juliano 2776 West Main Street Wapplngers Falls 13 10/05/1953
William K. Mlnkowskl 427 McGrath Blvd. . Flshklll 28 03/20/1942
Rosemarie Perretta 35 Cathy Road Poughkeepsie 8 09/07/1943
Gregory F. Sarno 13 Dana Place Wapplngers Falls 28 07/01/1936
Kenneth J. Tucker 34 Pawling Lake Pawling 9
Robert N. Wallner 7 Klnry Road Poughkeepsie 19 01/17/1933
'\() A/(I<i:ST BY THIS A
ACCOIWANCE WITIlINFO GEN~Y ON FILE IN
~;;7 RMAnON FURNISHED
\"G/~~ ~)
;)( 'TC 10 BUREAU -
. , IIESSCOUNTYSHER
150 NORl/ I HAMILTON S;~;; OFFIes
POU~EEPSIE, NY 12601
- ,'I/~ - 20LQ
-----.
Schedule 1: Officers and Directors
~OD'q t" ~')~
WAPPINGER LODGE #2609 OFFICERS for 2U- Irle-
Title
.---...------------ ------------. ------------------------- ----------------..--------..-
Name
Address
Exalted Ruler
Leading Kgn
LoyalKgn
Lect. Kgn.
Esquire
Chaplain
Inner Guard
Secretary
Treasurer
Tiler
Trustee
Trustee
Trustee
Trustee
Trustee
Joseph P. Havelka Sr.
Eileen E. Boyer
Diana Cole
Paul Bader
Mark H. Fox
Catherine Rohling
Rosemarie Perretta .
Robert M. Acquanlta
Pamela S. Kultsar
Susan Dorler
James Boyer
Rocco Valente
Alex Czarnleckl
Alfred DeRose
Vacant
38 Hickory Lane
134 Andrews Road
P.O. Box 549
134 Andrew~ Road
28 Tiger Road
54 Brothers Road
35 Cathy Road
10 Vorndran Dr.
68 Hillis Terrace
21 Valley Road
134 Andrews Road
61 Flshklll Hook Rd.
31 Hele.n Drive
25 Hickory Lane
No Officer receives compensation of any kind.
,\
Town Zip DOB
...-------------.-.---.--- -------- --------------------
Pawling 12564 11/13/1942
Lagrangevllle 12540 01/02/1943
Hughsonvllle It 12537 04/25/1948
Lagrangevllle 12540 09/20/1965
Hopewell Jet. 12533 09/15/1957
Wappinger Falls 12590 04/22/1940
Poughkeepsie 12603 08/07/1943
Wappinger Falls 12590 OS/25/1942
Poughkeepsie 12603 02/01/1950
Wappinger Falls 12590 03/29/1939
Lagrangevllle 12540 11/28/1937
Hopewell Jet. 12533 06/06/1941
Wappinger Falls 12590 10/16/1941
Pawling 12564 11/28/1961
-,
I
;C-2
lYS RACING & WAGERING BOARD
Walervliel Ave, Ex!.. SUil~ 2
IJbany, NY 12206-1668
relephone (518) 453-8460 Fax (518) 453-8492
/{ww,racing,slale,ny,us
APPLICATION FOR:
PLEASE CHECK L /
GAMES OF CHANCE ~
BELL JAR 0
RAFFLE 0
-----..--- - .~ ---------------
FOR OFFICE
USE ONLY
$\ ~~ O.Q
Fees Receiv~d
[QW / [ill] / [[Q]
Dat~
INSTRUCTIONS: PLEASE FILE THREE SIGNED COPIES WITH MUNICIPALITY
GC -llID - [2IillJ- ~- ~
N,Y,S, Identification Number
IT IS A MISDEMEANOR TO MAKE ANY FALSE STATEMENTS IN THIS APPLICATION
-raW", 0+ WAry/AljER JjC/-ft:1fiSr
Name of Municipality I County "
2,
3,
4. Ch~ck type of organization and. if applicable. give the State and date of incorporation.
Corporation 0
IIJf State incorporated N E fA) v 0 R k
Incorporated Association IDl. ~
Date [fTIfl / [QIZJ / [M
Date [[] / [[] / OJ
Unincorporated Association 0
State incorporated
Individual
o
S, Did your corporate status change since your identification nu,ber was assigned? 0 Yes IINo
6. Are you L10ing business under a trade name? 0 Yes ,-No If "yes". what is the trade name?
PART B. LOCA nON OF GAMES
7. Address where games, bell jar, or raffle drawing(s) are to be conducted. 11ft" !<f. 31(1 Wrf"7G.4J 6ft, Ai f IZJ'?O
8. Name nnd address, of authori~d games of IV fA .,"
chance lessor renting to applicant. /-!..
9. Does the applicant own the premises? WYes 0 No If "yes". how long?
11.
10. Capacity for public assembly of premises presently owned or occupied.
12. Are the premises or any part thereof
where games of chance are to be played
licensed by the State Liquor Authoriry?
J4 Yes ~o
If "yes", state the type of license and number.
CL- 000 11 t.{3
13, Has such license ever been If "yes", why? (Explain on a separate sheet. if necessary. and attach.)
revoked or suspended? 0 Yes _ No
L 8J-GC-2 (Ilev. 4/U3)
Page I of2
11111111111111111111111111111 .J
r
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PART C. PURPOSES OF GAMES
14. State the specific purposes for which the enf e net proceeds are to be devoted and in what manner.
I C f q.. 2. ()
I swear (or affirm):
I. That ALL the attached Schedules are a material part hereof and are incorporated herein as if set out in full in the application. All the answers
contained in this application are a material part hereof.
2. That the entire net proceeds of all games of chance shall be devoted exclusively to one or more of the "lawful purposes" as defined in the Games of
Chance Licensing Law and the Rules and Regulations ofthe 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 undersigned will be responsible for the holding, operation and conduct of alI games of chance in accordance with the terms ofthe license,
the provisions ofthe Games of Chance Licensing Law, the Rules and Regulations ofthe N.Y.S. Racing & Wagering Board and with the provisions
of local licensing ordinances or laws.
5. That the undersigned has read and is familiar with the provisions of the Games of Chance Licensing Law as amended, the Rules and Regulations
of the N.Y.S. Racing & Wagering Board, and the local licensing ordinances or laws.
6. That no commission, salary, compensation, reward or recompense wilI be paid to any person for holding or assisting in the operating or
conducting of the games, except to bookkeepers or accountants for professional services in an amount not exceeding that fixed by the Board.
STATE
OF
c
A/Ex f? C-z.M'tf/tcckl
Print Name
@IfJ / [Ql2] / [2]Q]
Date
COUNTY
OF
7)c) tel 6. l' J
ss
W~PPIAJ/512
/) , ,
r, C ~ A~ NI f t / being duly sworn deposes and says that (s)he is the person above named,
that (s e as 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.
(;iIIIf/TOWN/~~
OF
daYOf~, 20~
Signed A\~ ~. c..'1:-Qf(\i~<-lt
Commissioner of Deeds
Public
My Commission expires ~.eu~ ( \
,20~
. KAREN SPENGLER
Notary Public ~State cit New York
NO.01SP6197430
Qualified in Dutchess County
My Commission Expires
L BJ-GC-2 (Rev. 3/06)
Page 2 of2
11111111111111111111111111111 .J
-
I
GC-2B
IfYS RACING & WAGERING BOARD ,
I Watervliet Ave. Ext., Suite 2
~bany. NY 12206-1668
relephone (518) 453-8460 Fax (518) 453.8492
I/WW .racing.state.ny.us
APPLICATION FOR GAMES OF
CHANCE LICENSE
GC- [ill] - [1[ili] - ~ - ~ 16 ~I / 16171/ [QIjJ
NYS Identification Number ' Date
iCHEDULE 5 DATES, HOURS AND RENT OF ALL LICENSE PERIODS TO BE HELD
(NOT APPUCABLE FOR BELL JAR. GAMES)
DATE HOURS
o ~ / .Q!1 f . I. O.! .0.1 .:.6.0 III/pm - . / .2-.:.0.0 _/pm!$ ,
----.... f . . f . ,! . ... .am/pm - . ::. ,am/pm !$.
----.... / " . f . .! . .:. .am /pm - . ,:. ,am /pm ! $ .
----.... f, . f . .! . ,.. .am/pm - . .:. ,am/pm !$.
----.. f . . f , .! , .:. .am/pm - . ,:. .am/pm !$.
----.. f . . f . ,! . ,:. ,am/pm - .' .:. .am/pm '!$ ,
, . f . . f . .! . ,:. .am /pm - . .:. .am /pm ! $ .
______ / . . f . .! . .:. ,am/pm - . .:. ,am/pm! $.
----.. f . . f . .! . , . . .am / pm - . . : . .am / pm ! $ .
. ./. .f. ,!. .:. .am/pm-, .:. ,am/pm!$.
. .f. .f. .!, .:. ,am/pm-. .:. .am/pm!$.
, . / . . f .! . ,:. ,.am /pm - . .:. .am /pm' ! $ .
RAFFLES
DATE
RENT
. . .
. . .
,-,
. . .
6. .
. . .
. . .
1.'
I-'
. . .
. . .
. . .
.
.. .
am/pm -
. .
.am/pm - .
am/pm -
. ..
am /pm -
. .
am/pm -
. r
.
.. .
PRIZES (Cash or Fair Market
Value of Merchandise)
.am/pm !$. . , . . .,. .
,am/pm '$. . . . . .., .
.am/pm \$ ,.,
.am/pm !$. ...
.am/pm \$. ..,
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.
ITEM OF EXPENSE VENDOR N~ STREET ADDRESS CITY ST A'IE
/-'tv." Lr<fPle ft.if,ch",ff6J. ~v!fi(l II~ 12-1. '37b ~r;;:';HIJt IV If
FOf) J BI f~ Lo~q 5- .f1- 2.60'1. /I ~J,el-. 11t '7"'~ It IVY
.f
.f
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.
.. .
. I .
.
. . .
.
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ZIP
/2-S90
( tr? tJ
BJ.GC.2B (Rev. 4/03)
-
Page 1 of2
111\1\\111 \IIIII\\IlI\I\1\1I1 -.J
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 0412411940
Philip A Abbate 6 Hackensack Hghts Rd Wapplngers Falls 18 05116/1937
Robert Acquanita 10 Vorndran Drive Wapplngers Falls 22 OS/25/1942
Ralph J. Anzlvlna 12 T horns Lane Highland 22 12121/19~5
Henry J. Boldrln 28 Gold Road Wappinger Falls 15 01/11/1936
Harold A Crawford Sr. 318 Sunset Hili East Flshklll 18 02123/1936
Francis J. DeGano 27 Brandy Lane Wapplngers Falls 18 07/18/1946
Roger DeJordy 83 Kent Road Wapplngers Falls 18 09/19/1944
Robert Fischetti 91 Ardmore Drive Wappingers Falls 28. 06107/1926
Mark H. Fox 28 Tiger Road Hopewell Jct. 14 09/15/1957
Harris C. . Jones 217 Brothers Road Stormvllle 18 04/24/1944
Robert J. Juliano 2776 West Main Street Wapplngers Falls 13 10/05/1953
William K. Mlnkowskl 427 McGrath Blvd. Flshklll 28 03/20/1942
Rosemarie Perretta 35 Cathy Road Poughkeepsie 8 09/07/1943
Gregory F. Sarno 13 Dana Place Wapplngers Falls 28 07/01/1936
Kenneth J. Tucker 34 Pawling Lake Pawling 9
Robert N. Wallner 7 Klnry Road Poughkeepsie 19 01/17/1933
~ r SCHEDULE 7 TYPES OF GAMES -,
List all of the single types of games to.OO conducted at all license periods enumerated in Schedule 5.
Note for VeflBS Niehts 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)
(31.- A Ck 7ACk
J (j f< E R. ,0 0 J<. t: (C.
~)(, SiX wHEEL
For Merchandise Wheels, Bell 'Jars and Raftles, 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 APPLICATION
IS FOR A BELL JAR
LICENSE
YESO NO 0
THE TOTAL AMOUNT OF PAYOUTS
FOR EACH BELL JAR DEAL SHALL NOT
EXCEED $3,000 ~ NO SINGLE PRIZE
SHALL EXCEED $500
RAFFLES:
INDICATE lFTHlS APPLICATION
IS FOR A RAFFLE
LICENSE
YESO NO 0
IF YES, LIST RAFFLE DATES, TIME(S)
OF DRA WING(S) AND PRIZES IN
SCHEDULES
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 BJ-GC-IB (Rev. 3/06)
Page 2 of2
mlllllllllll~W I U UI .J
r
GC-2A
APPLICATION FOR GAMES OF CHANCE UCENSE
..~'
~~, ....;:~.:.:.r~. 'l".'~ ,
["h" "" .;' -".
',,~;~
'", -:;.;.... ..1
.,.... - "~t'l.r""I~ It;'.
NYS RACING &: WAGERING BOARD
1 Broadway Center, Suite 600
Scbeucctady, NY 12305-2553
Telephone (518) 395-5400 Fax (518) 347-1469
www.raciu..statc.ny.us
GC-Iiljl- r1f/lCjl-161612\- ~
NYSI~tio~
SCHEDULE 1: OFFICERS AND DIRECTORS
LiSlllllDlCS. lIddresscs and dates of birth of all officetS.
u_~...........n~~-:"\DA.;;oj;'mRTIi'~ET ADDRESS
~{j }4ffA-<.b6J (b.~IiI...).I_I_I_! I
L 1_1_1_1 I
I '_1_1_1 I
I 1_1_1_1 I
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Attach additional sheet if necessary.
[ili] , [Q[1] , [QE]
Date
CITY
SCHEDULJ:l.: 2: MEl\-ffiERS IN CHARGE OF GAMES
(MUST UST AT I.E^ST fOUR MEMBERS or APPUC^NT ORGANIZATION)
D1\ TE YEARS OF
~:~r~~:! m~MB!;r:IJ~;:/A~J:~:~r~J.. LA~~tr
~(Y\orv }<Avt.m...rJ! _-.al-L. b.' lmi 7~S~~;w~' ~~_~ J.I'lJfi I f
~!-:J-'-ll/~ t f.__.~fj./o!_~"JL;.J, 1M " :4J
bR6J _~4JtAlO : ___-1_I___.1_'~! 2& J 4c.ii tfJ 1/1
: IIi
:-1-'-'
-,-,-
=,=,=
I I
SCHFnI 1 Lt,', .~~ Arr'X{f .IAJH"I."~'1f1l ,IATIf. ORGANIZATIONS ASSfSTfNC AT GAMES
;"!LA. \",;; :>,1 i\::' :> .~; ;~.,H.1Al{IE~;!;\FFIUAns L\CIT AlT)(T1.1....I~ YiAFF11'^TF i .ISn'.I)?ji ".;., I 1,\ VI n', uw:-! II) NUMIU"!I i
NAME OF A(iX[!!ARY/APFIUATE
(rAMES OF CHANCE II) NUMBER
11111111111 .J
L BJ-G(:-H (Rn'. 3iO'; l
Page I 01'2
I
ZIP
ZIP
JU~O
}LS'33
I z. J9tJ
/ Z!"?tJ
r SCHEDULE 4: ASSIST ANTS TO MEMBERS IN CHARGE OF GAMES
List all ~ of applicant orgaoization and members of authorized affiliates and auxiliary who will assist with games" Each person listed must be a
member of applicant orpnization or affiliate for at least I year"
YEARS OF
(JMBER NAME DATE OF BIRTH MEMBERSH~ {TREET ADDRESS
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L BJ-GC-1A (Rev. JI06)
Attach additional sheet if necessary.
Page 2 of 2
CITY
--,
ZIP
11111111111 .J
Schedule 1: Officers and Directors
~Oe'cr C" ~'l~
WAPPINGER LODGE #2609 OFFICERS for 211- In9'
Title
---...------------- .... -----.- -..- ----------------.....-.-----.. --------------- --- ------- --.....
Name
Address
Exalted Ruler
Leading Kgn
LoyalKgn
Lect. Kgn.
Esquire
Chaplain
Inner Guard
Secretary
Treasurer
Tiler
Trustee
Trustee
Trustee
Trustee
Trustee
Joseph P. Havelka Sr.
Eileen E. Boyer
Diana Cole
Paul Bader
Mark H. Fox
Catherine Rohling
Rosemarie Perretta .
Robert M. Acquanlta
Pamela S. Kultsar
Susan Dorler
James Boyer
Rocco Valente
Alex Czarnleekl
Alfred DeRose
Vacant
38 Hickory Lane
134 Andrews Road
P.O. Box 549
134 Andrew~ Road
28 Tiger Road
54 Brothers Road
35 Cathy Road
10 Vorndran Dr.
68 Hillis Terrace
21 Valley Road
134 Andrews Road
61 FlshklllHook Rd.
31 Hele.n Drive
25 Hickory Lane
No Officer receives compensation of any kind.
Town Zip DOB
...------.-..--.....----.-..- ..------. -------------------.
Pawling 12564 11/13/1942
Lagrangevllle 12540 01/02/1943
Hughsonvllle . 12537 04/25/1948
Lagrangevllle 12540 09/20/1965
Hopewell Jet. 12533 09/15/1957
Wappinger Falls 12590 04/22/1940
Poughkeepsie 12603 08/07/1943
Wappinger Falls 12590 OS/25/1942
Poughkeepsie 12603 02/01/1950
Wappinger Falls 12590 03/29/1939
Lag rangevllle 12540 11/28/1937
Hopewell Jet. 12533 06/06/1941
Wappinger Falls 12590 10/16/1841
Pawling 12564 11/28/1961
-_.....__.__._..~_._---,._------.__._---,.__.__._.~._---""-~___n
ALEX P. CZARNIECKI ~ 5382
WA~~~~~:D~~~~~;;~~~05__~/!'~ 0___' DATE 50-7936/2219
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= ii." Federal Credit Dmon
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I: 2 2 ~ ~ ? ~ :I b :II: 0 0 000 :I 2 ~ b ~ 5 ~ ~ ~ II- 5 :I B 2 '-7-_!'
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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
--,
FINDINGS AND
DETERMINA nON
FOR GAMES OF CHANCE
LICENSE
GC - m - GIlGl - ~ - GliIQI!LJ
N.Y.S. Identification Number
Name of Applicant Organization
1195 Route 376, Wappingers Falls, NY 12590
Address
nicipal Law, the following findings and determinations
After investigation. and a hearing if required under Sec. 192 of
have been made:
1. All the members-in-charge designated in the
character and have never been convicted of
Signature of Person Conducting Investigatio
[!"Yes 0 No
S h €-r,-?r
Title
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 accordan~e with the
provisions of the Games of Chance Licensing Law.
9. If applicable, the rent Lo be paid to an authorized games of chance lessor is reasonable.
10. Other findings: (Specify)
&I Yes DNo
iI Yes DNo
&I Yes DNo
IX! Yes DNo
IX! Yes DNo
IX! Yes DNo
lXI Yes DNo
rn Yes DNo
DYes DNo
slill,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 ~eY. 4/03) 1111111I1111111111111111I1111 .J
TO BE COMPLETED BY MUNICIPAL CLERK.:
As a resulL of the findings and determinations stated above, license is GRANTED ~ense is DENIED 0
Signature of
Filing date of Application May 11, 2010 Authorized Officer
Date
Title
Town Clerk
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GC-2A
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APPLICATION FOR GAMES OF CHANCE liCENSE
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NYS RACING &: WAGERING BOARD
I Broadway Center, Suite 600
Schcncctady, NY 12305-2553
Telephone (518) 395-5400 Fax (518) 347-1469
www.racin.stale.ny.us
GC- fIT3l- r:7Tjlql- 1616121- ~
NYSI~tio~
SCHEDULE 1: OFFICERS AND DIRECTORS
Usl names, addresses and dales of birth of all officers.
If lIIpIIizIdion is . clll'JlCD!ioo, or an illCOl'pOAlCd 01' 1IIIi_l"llalcd -wboo, list officers and directOl'S.
~ I NAME, , \ DATE OF BIRTH I STREET-ADDRESS
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Attach additional sheet if necessary.
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Date
CITY
ZIP
MEMBERS IN CHARGE OF GA"MES
(MUST I.IST AT I.EAST fOUR MEMBERS OF APPLICANT ORGANIZATION)
DA TE YEARS OF
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io.','\ ',:"" '~,l nl' ~ A ()',lI IARIE:)'/\I.TILI,WJ":;. fACIT Al n(JIIl'.I~Y'M-FlIl^H I.lS" },I) i~~~b~;il\i"I~M;[:rON STR~~(:)jff,Q
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SCHEDULE 2:
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