Wappingers Elks Lodge (5)
r--
GC-2B APPLICATION I<'OR GAMES 01<'
!\iTS KAClNG 8: WA(iEK1NCi BOAHD CHANCE LICENSE
I W,ller\'li~l A\'e. Exl., S\Ille 1
r\thall}. NY 122(lO-lot>H
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Narnt.' uf OrganJl.alion
GC - [ill] - [1IL@] - [6Jill] - [Qli]QIili]
NY S Ldenlificallon Number
16lzJ / 10 f7--1 / ID f(j-j
Dale
SCHEDULE 5 DATES, HOURS AND RENT OF ALL LICENSE PERIODS TO BE HELD
(."IOT APPLiCABLE FOR BELL JAR GAMES)
DATE '
03 / 0 S- / I 0
0'1 /.0.2./ J 0
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HOURS
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RENT
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RAFFLES
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PRIZES (Cash or Fair Markel
Value of' Merchandis~)
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:$
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:$
DATE
TIME
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S('HEUlILE 6 EXPENSES
LJS! I(ems of c.\.pense lO be incurred, and lhe names and addresses of persons lO be paid.
ITEM OF E.\J>t::NSJ:::' VENDOR NAME STREET ADDRESS CITY STATE
J.llIlC~ L,aJrvs?, fA.d Gxh.tt/f6cJ Rvl6n 1''1~- {(I, 37 b f)/tfl-i'iGifJ /;./11 N V
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1I11111111111~ IIII1I1IIII1 -.J
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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:85 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
(Limit: 5 Games)
(31- A Ck -rACk
JO /< G (( ,001< E/C
f!;,)6 S)x 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 APPLICA nON
IS FOR A BELL JAR
LICENSE
YESO NO 0
THE TOTAL AMOUNT OF PAYOUTS
FOR EACH BELL JAR DEAL SHALL NOT
EXCEED $3,000 AND NO SINGLE PRIZE
SHALL EXCEED $500
RAFFLES:
INDICATE IF THIS APPLICA nON
IS FOR A RAFFLE
LICENSE
YESO NO 0
IF YES, LIST RAFFLE DATES, TIME(S)
OF DRA WlNG(S) AND PRIZES IN
SCHEDULE 5
THE TOTAL AMOUNT OF PRIZES FOR
ALL THE RAFFLES CONDUCTED DUR-
ING THIS CALENDAR YEAR SHALL
NOT EXCEED $100,000. NO SINGLE
PRIZE SHALL EXCEED $50,000
EXCEPT THAT A SINGLE PRIZE OF
$100,000 MAY BE AWARDED IF SO
INDICATED IN SCHEDULE 5
L BJ-GC-2B (Rev. 3106)
Page 2 of2
111111111111 -.J
r'
GC-2
-,
NYS RACING & WAGERING BOARD
1 Walervliel Ave. Ext, Suile 2
Albany, NY 12206-1668
Tlllephone (:'\ 18) 4:'\3-8460 Fax (518) 453-8492
www.racing.slale.ny.us
APPLICATION FOR:
PLEASE CHECK
GAMES OF CHANCEje(
BELL JAR 0
RAFFLE 0
FOR OFFICE
USE ONLY
$1 I rn Tt::IJTCOl
Fees Received Date
INSTRUCTIONS: PLEASE FILE THREE SIGNED COPIES WITH MUNICIPALITY
GC-[lli]-~-~- ~
N.Y.S. Identification Number
IT IS A MISDEMEANOR TO MAKE ANY FALSE STATEMENTS IN THIS APPLICATION
tOWN of WA-ff/NG-6R- vUlcl+ESS
Name of Municipality County
I.
2.
3.
4. ('-heck type of organiution and, if applicable, give the State and date of incorporation.
Corporation 0
Incorporated Association ~ State incorporated N E- W Yo R It(
Unincorporated Association D
State incorporated
Date I o[f) / [Q[2] / Gill]
Date [[] / [[] / [[]
Individual
o
5. Did your corporate status change since your identification nu~r was assigned? D Yes ~ No
. No If "yes", what is the trade name?
6. Are you doing business under a trade name? 0 Yes
PART B. LOCATION OF GAMES
7. Address where games, bell jar, or caftle drawing(s) are to be conducted.
N/A
,
/ I 'IS- i2f. 376 uJ1f'^7litfJ hflJ Aly' / 2S-9~
8. Name and address of authorized games of
chance lessor renting to applicant.
9. Does the applicant own the premises? M Yes 0 No If "yes", how long'!
1-g-b
11. Have premises been regularly used? lit Yes 0 No If "yes", how long? '2 '3 V G A-R S
Are games of chance being flayed now on these premises or has it ever been? if Yes 0 N/If "yes", give full details.
LAS+ D.4t6' FEbRUAl<..tI S--. 20/0
/ '
If "yes", state the type of lict:.nse and numher.
. Yes DNo C L- - 000 7 i 2- 43
J O. 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 Stale Liquor AUlhority?
13. Has such license ever been
revoked or suspended? DYes
~NO
If "yes", why? (Explain on a separate sheet, if necessary, and attach.)
L 8J.GC.2 (Key. 4/03)
Page I of2
IIIIIIIIIIIIIIIIIIIIIIIII~ II .J
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I
PART C. PURPOSES OF GAMES
14. State the specific purposes for which the ertire net proceeds are to be devoted and in what ranner.
1/3 ChAtZ.,fA Jo / G +- 2../3 O/JI5Il/tfIOtJ.J
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I swear (or affirm):
1. 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 all games of chance in accordance with the terms ofthe 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 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 will 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.
[QliJ II DIS'II [2]g f? ~ J. / he I? CZ-A/CN ltiek.
Date Signature fHead of ganization Print Name
-r~IIJTe C.J.4A,..It.{t\"";..)
NEW YORK
V <J+c~6-SS
OF WAftINJE~
A \ ex P C ~rn;eLKi I 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.
STATE
OF
ss
COUNTY
OF
"'TOWN/\.:p. __ 17
Signed .dJ <J<. f C")..Q r N Ie c C-:
Commissioner of Deeds
o Public
My Commission expires ~ I (') :l-
(
,20lL
SANDRA E GRASBY
Notary Public. State of New York
NO.01GR6192375
Qualified In Dutchess Cou
My Commission Expires 0
L BJ-GC-2 (Rev. 3/06)
Page 2 of2
11111111111111111111111111111 ~
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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
Schenectady, NY 12305-2553
Telephone (518) 395-5400 Fax (518) 347-1469
www.rac:ing.stale.ny.us
WAf NGE~
Name of Organization
GC- ~ - [JJili] -1616121- ~
NYS I~tion Number
SCHEDULE 1: OFFICERS AND DIRECTORS
List names, addresses and dates of birth of all officers_
If organizaIioq is a corpondioa, or an illCOl'pOl8tod or uninc:orpondl:d assoei8tion, list officers and din:ctors.
0E ~ NAME ~ D DATE OF BIRTH I STREET ADDRESS .
S/35 ritM 6,1 (r;,1i 1_1_1_1 I
1_1_1_1 I
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Attach additional sheet if necessary.
[Qli] I [QU] I [QH]
Date
CITY
ZIP
SCHEDULE 2: l\iErvmERs IN CHARGE OF GAMES
(MP3T UST AT LEAST FOUR MEMBERS OF APPLICANT ORGANIZATION)
DA TE YEARS OF
PAfJ J:n~J f~ ; ~/ ~~;ll n6~~Mnr1SHH~;4~A;'~J :~)~~I'SRJ.
.1;"'0'" j<..J",,.rJi!ll_j(,j ji3~! 7 ..~~~.__
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CITY
'fiD
'i.-f'HFHI TF "'\FXO J "IH'ft\FFH ,IATF ORf;ANIZATIONS ASStS'lT'\JG AI' GA~IES
""'. ",. .~_nXH.LbJ~.JES.;/\.FFILtATl:-~~_ r,-\ClTld)Xn,!Al~Y/f..r;f7ILf/..Tf--':I.lS'iVl)tvi!.'\T~ _, n ~i\;\' ;j\;; I ~,"~,(iL'
NAMF (}!- Al iX!!.!ARY/AFF!UATE
GAMES OF CHANCE BJ NUMBER
L B.I--GC--l-\ tRe,. J/%)
Page t of2
II1IIIIII11 .J
Schedule 1: Officers and Directors
~OD'cr r- ~~~
WAPPINGER LODGE #2609 OFFICERS for 2"- In8:..
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. Kultaar
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.
58 HIllis Terrace
21 Valley Road
134 Andrews Road
61 Flshklll Hook Rd.
31 Hele" Drive
25 Hickory Lane
No Officer receives compensation of any kind.
Town Zip DOB
__.._______._._ __...___...___.. ._a _.____...... ...__a_._____..______.
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 05/25/1942
Poughkeepsie 12603 02/01/1950
Wappinger Falls 12590 03/29/1939
Lagrangevllle 12540 11/28/1937
Hopewell Jct. 12533 06/06/1941
Wappinger Falls 12590 10/16/1941
Pawling 12664 11/28/1961
r SCHEDULE 4: ASSISTANTS TO MEMBERS IN CHARGE OF GAMES
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 organization or affiliate for at least 1 year.
YEARS OF
~EMBER NAME DATE OF BIRTH MEMBERSHIP ~TREET ADDRESS
_5 be A-r-rft/U1:l?b t-if.-r:7-
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L BJ-GC-1A (Rev. 3106)
Attach additional sheet if necessary.
Page 2 of2
CITY
--,
ZIP
III11III1II -I
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 Wappingers Falls 18 05/16/1937
Robert Acquanita 10 Vorndran Drive Wappingers Falls 22 OS/25/1942
Ralph J. Anzivlna 12 Thorns Lane Highland 22 12121/19~5
Henry J. Boldrin 28 Gold Road Wappinger Falls 15 01/11/1936
Harold A. Crawford Sr. 318 Sunset Hill East Fishklll 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 06/07/1926
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 Wappingers Falls 13 10/05/1953
William K. Mlnkowski 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 APPLICATION J:t'OR GAMES O.~
!\iYS I{ACING & WA(iEI{IN(j BOAHD CHANCE LiCENSE
I \"'ul~r,'lil:.1 A\'e, Exl., SUite :2
,\Ihdll). NY 1220l'l..loIIX
Tdephlllle is Ill) 4S~\-1l4()O b\ (5111) 45,\ ~WJ'l
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NY S lden(ificallOn Number
[6121 / 1017-\ / \0 fCj-j
Dale
SCHEDULE 5 DATES, HOURS AND RENT OF ALL LICENSE PERIODS TO BE HELD
I ,"'lOT APPLlCABLE FOR BELL JAR GAMES)
DATE .
03 / OS' / I 0
0'1 /,0,2. / : I 0
.J2~~ I .tL2 / __LJ2:
I I
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HOURS
D, 7.:~Q.JIII/pm .. ./.2,:. O. O.am/.-.I$.
O. 7 ,: 0 0.../ pm ..
o 7 0.0 .~/plll ..
RENT
I 2.: 0 0 am 1__ i $
J.2:0.0am/1K!$.
am/pm i$. .
~_. -
ami pm ! $
am I pm I $ . ,
ami pm : $ '-----'--~
am / pili ,$
,am fplll '$,
am / pm ; $
,am / pm : $ .
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am/pm ..
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RAFFLES
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PRIZES (Cash ur Fair Markel
Value of Merchandisd
!$.
i$.
'$
,
:$,
!$
DATE
TIME
I
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SCHEDULE 6 EXPENSES
LISl l[elTlS of expense to be incurred, and the names and addresses of persons to be paid.
ITEM OF EXPENS.I::.' VENDOR NAME STREET ADDRESS CITY STATE
tllv~11, L,<.aN.f~ fAir ~xJ,.'t1f6,1 Rv16!l 119~- {(f, '37 f:.' {)Itf'....r3.If.J ~/ll NY
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ZIP
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1111111 11111111111111111111 -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 Vef!as 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
(Limit: 5 Games)
13L- A Ck -rf\Ck
J () /< G R. f> 0 k E: {(
f!>i& SiX wHEEL
For Merchandise Wheels, Bell Jars and Raftles, please complete the appropriate spaces below.
MERCHANDISE WHEELS:
INDICATE NUMBER OF
MERCHANDISE WHEELS
(NO LIMIn
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
YESO NO 0
THE TOTAL AMOUNT OF PAYOUTS
FOR EACH BELL JAR DEAL SHALL NOT
EXCEED $3,000 AND NO SINGLE PRIZE
SHALL EXCEED $500
RAFFLES:
INDICATE IF THIS APPLICATION
IS FOR A RAFFLE
LICENSE
YESO NO 0
IF YES, LIST RAFFLE DATES, TIME(S)
OF DRA WING(S) AND PRIZES IN
SCHEDULE 5
THE TOTAL AMOUNT OF PRIZES FOR
ALL THE RAFFLES CONDUCTED DUR.
ING THIS CALENDAR YEAR SHALL
NOT EXCEED $100,000. NO SINGLE
PRIZE SHALL EXCEED $50,000
EXCEPT THAT A SINGLE PRIZE OF
$1 00,000 MAY BE A WARDED IF SO
INDICATED IN SCHEDULE 5
L BJ-GC-IB (Rev. 3106)
Page 2 of2
IIlIIIIIUII ..J
ALEX P. CZARNIECKI
ISMAY CZARNIECKI
31 HaENDRIVE 845.297-6083
WAPPINGERS FALLS, NY 12590.1705
' R\Y TOTHE.,-;'"""t
ROP OWN (1
DATE
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5360
50'7936/2219
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DOLLARS 6J E:~~
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