Fillable APPLICATION FOR PERMIT TO CONDUCT BINGO CHARITABLE GAMES (Town of Somers)

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APPLICATION FOR PERMIT TO CONDUCT BINGO CHARITABLE GAMES (Town of Somers)

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INSTRUCTIONS:
1. Print or type and, if necessary, use additional sheets. Have application notarized.
2. The completed form must be mailed to:
TO:
PERMIT NUMBER
NAME OF ORGANIZATION
IDENTIFICATION NUMBER
ADDRESS OF ORGANIZATION (No. and Street) (City or Town) (State) (Zip Code) DATE ORGANIZED
MAILING ADDRESS (No. and Street) (City or Town) (State) (Zip Code) TELEPHONE NUMBER
OFFICERS OF THE ORGANIZATION
NAME (Last, First, Middle) TITLE NAME (Last, First, Middle) TITLE
1.
3.
2.
4.
ORGANIZATION MEMBERS WHO ARE HOLDERS OF PERSONAL IDENTIFICATION NUMBERS
(Designate Member-In-Charge’s Name With An Asterisk)
NAME (Last, First, Middle) P.I.N. NAME (Last, First, Middle) P.I.N.
1.
5.
2.
6.
3.
7.
4.
8.
MEMBER IN CHARGE: Is the Member in Charge a bona-fide, active member of the
organization and a member in good standing for at least six months?
YES NO
Check Type of Permit Applied for and Indicate Day(s) and Date(s):
CLASS A (One day each week from issue date to 9/30) (Fee: $ .00)
DAY OF
WEEK: _______________ TIME: _______________ TO: _______________
CLASS B (Maximum of ten successive days) (Fee: $ .00 per day)
DATE: __________ TO: __________ TIME: __________ TO: __________
CLASS C (One day each month from issue date to 9/30) (Fee: $ .00)
JAN ____/_____/____
am
FROM: __________pm
am
TO: ___________pm
JUL ____/_____/____
am
FROM: __________pm
am
TO: ___________pm
FEB ___
_/_____/____
am
FROM: __________pm
am
TO: ___________pm
AUG ____/_____/____
am
FROM: __________pm
am
TO: ___________pm
MAR ____/_____/____
am
FROM: __________pm
am
TO: ___________pm
SEP ____/_____/____
am
FROM: __________pm
am
TO: ___________pm
APR ____/_____/____
am
FROM: __________pm
am
TO: ___________pm
OCT ___
_/_____/____
am
FROM
: __________pm
am
TO: ___________pm
MAY ____/_____/____
am
FROM: __________pm
am
TO: ___________pm
NOV ____/_____/____
am
FROM: __________pm
am
TO: ___________pm
JUN ____/_____/____
am
FROM: __________pm
am
TO: ___________pm
DEC ____/____
_/____
am
FROM: ___
_______pm
am
TO: ___________pm
ADDRESS WHERE BINGO WILL BE PLAYED (No. and Street) (City or Town) (State) (Zip Code) MAXIMUM SEATING
CAPACITY ACCORDING
TO LAW:
WHO OWNS THESE PREMISES? (Name) (No. and Street) (City or Town) (State) (Zip Code)
RENTING/LEASING?
YES NO
FOR OFFICE USE ONLY
I, the undersigned ranking officer of subject organization, do hereby state that all Bingo sessions
operated by subject organization under this permit will be conducted in compliance with the
Connecticut General Statutes and with all Administrative Regulations concerning Bingo Games.
SIGNED (Ranking Officer)
DATE (Mo., Day, Yr.
Personally appeared the signer of the foregoing statement and
made oath before me to the truth of matters contained therein.
SIGNED (Notary Public)
MY COMMISSION EXPIRES:
DATE (Mo., Day, Yr.)
Application for Bingo Permit is approved
DATE (Mo., Day, Yr.)
APPLICATION FOR PERMIT
TO CONDUCT BINGO
CHARITABLE GAMES
SAMPLE
St. John's Church - Men's Club
1700005
263 Cedar Mountain Road, Anytown, CT 06000
06/20/65
c/o Reverend Smith, 261 Cedar Mountain Road, Anytown CT 06000
(860) 555-1000
Couto, William E.
President
Vice President
McDonald, Edward T
Treasurer
** Boudreau, Alan**
016275B
Cuoto, William E.
015327B
Levesque, Henry
016276B
Markow, Brian M.
014412B
McDonald, Edward T.
016162B
Rogers, Leonard A.
016277B
Thom, Ned (applying for no.)
Yas, John (applying for no.)
✔
✔
Monday
7:00 pm
10:00 pm
263 Cedar Mountain Road, Anytown CT 06000
250
St. John's Church 263 Cedar Mountain Road, Anytown CT 06000
✔
William E. Cuoto
08/28/11
Frank Smead
08/28/11
04/03/15
INSTRUCTIONS:
1. Print or type, and attach all required material.
2. The completed form must be mailed to:
TO: DEPARTMENT OF CONSUMER PROTECTION
IDENTIFICATION NUMBER
MEMBER IN CHARGE
Name (please print):
Home telephone number: ( )
Work telephone number: ( )
I, the undersigned Member In Charge of the subject organization, do hereby state that I have read the Connecticut General Statutes
governing Bingo and the Administrative Regulations, Operation Of Bingo Games, and that I will be responsible for the holding,
operation and conduct of all Bingo sessions in accordance with the terms of the permit, and the provisions of the Bingo law and the
administrative regulations governing Bingo.
SIGNED (Member In Charge) DATE (Mo., Day, Yr.)
BINGO SESSION
Provide the time the doors open to the public:
Provide the time the sale of cards or sheets begins:
Provide the time balls will be drawn for the bonanza game (if any):
Provide the time the bingo games will commence:
SPECIAL BINGO BANK ACCOUNT
Account number:
Attach a voided (not cancelled) check from the special bingo bank account in the space provided below:
Special Bingo Bank Account I.D. #1700005 Class A 51-3849 1016
St. John’s Church – Men’s Club 3204
263 Cedar Mountain Road, Anytown, CT 06000
DATE: _________________________________
PAY TO
THE ORDER OF:
$ ______________________
DOLLARS
THE FIRST NATIONAL BANK
MEMO
SIGNED ____________________________________________________
|:320438491 |:10 0003629900 ||' 1016
ATTACHMENT
Attach one original identifiable admission card, sheet or ticket. A photocopy is not acceptable.
BINGO SUPPLEMENTAL FORM
SAMPLE
1700005
Alan Boudreau
860 555-3200
860 555-3750
Alan Boudreau
08/28/11
5:00 pm
5:30 pm
6:45 pm
7:00 pm
10 0003629900
INSTRUCTIONS FOR COMPLETION OF AN APPLICATION FOR BINGO PERMIT
1. Do NOT fill-in a permit number. A new permit number is assigned to each
organization annually.
2. Print or type the name of the sponsoring organization, the complete organization address
(number, street, town, state, zip), and a complete mailing address. If renewing a
permit, please use exactly the same organization name given on previous applications.
3. List the seven (7) digit organization Identification Number previously assigned by the
Department.
4. Provide the complete date (month, day, year) the organization was organized.
5. Print the telephone number of the sponsoring organization.
6. List the complete name (last, first, middle) and the title of each officer of the sponsoring
organization. An additional sheet may be attached, if necessary.
7. List the complete name (last, first, middle) and Personal Identification Number (PIN) of
all members of the sponsoring organization assigned to assist in the operation or conduct
of bingo. Additional sheets may be attached, if necessary. Please Note: Members who
desire to apply for and receive a PIN should submit an application along with this
application form and should also be listed under the section titled Holders of
Personal Identification Numbers. A notation must be made beside their name that
an Application for Personal Identification Number (PIN) Bingo form is also attached
and submitted for approval.
8. Designate only ONE individual as Member In Charge of the bingo sessions. In order
to designate the Member In Charge, an asterisk (*) must be placed beside the name
of one of the individuals listed in the section titled Holders of Personal Identification
Numbers. Please take note that the designated Member In Charge must have previously
applied for and received a PIN for the organization that he/she will be the Member In
Charge of, or an Application for Personal Identification Number (PIN) Bingo form must
be submitted for this individual along with this application form.
9. Answer the question in regard to the Member In Charge by indicating whether or not the
Member In Charge is a bona-fide, active member of the organization and a member in
good standing for at least six months.
10. Check the type of permit for which your organization is applying. ‘Class A’ bingo
permits allow bingo sessions to be conducted one day per week for the current calendar
year, (Jan 1 through December 31); ‘Class B’ bingo permits allow an organization to
conduct bingo up to ten successive days; and ‘Class C’ bingo permits allow bingo
sessions to be conducted one day per month for the current calendar year. (Jan 1 through
December 31); If applying for a ‘Class A’ bingo permit, the day of the week the
Page 2
Instructions For Completion Of Bingo Permit Application
sessions will be conducted must be provided along with the commencing time and the
terminating time (including a.m. or p.m.) of the sessions. If applying for a ‘Class B’
bingo permit, the commencing date and the terminating date (month, day, year) the
sessions will be held must be provided along with the commencing time and the
terminating time (including a.m. or p.m.) for each day the sessions are to be conducted.
If applying for a ‘Class C’ bingo permit, the complete date (month, day, year) the
sessions will be held for each month must be provided, along with the commencing time
and the terminating time (including a.m. or p.m.) for each date the sessions are to be
conducted.
11. Print the complete address (number, street, town, state, zip) of the location where the
bingo sessions will be held, and indicate who owns these premises by providing a
complete name and address (name, number, street, town, state, zip).
12. Print the maximum seating capacity according to law, and answer the question in regard
to renting or leasing the premises where the sessions are to be conducted.
13. Have the application signed and dated by one of the ranking officers of the organization.
Please take note that only individuals listed on the application in the section titled
Officers Of The Organization qualify as ranking officers.
14. The application form must be signed and dated by an authorized Notary Public. Please
be sure that the notary seal and/or the date the Notary Public’s commission expires are
used on this document. Applications will not be accepted without this important
information.
15. Attach a check, made payable to the “ ” for the
appropriate permit fee. Please take note that checks must be drawn from the
sponsoring organization’s “Special Bingo Bank Account” when applying for a ‘Class
A’ or ‘Class C’ bingo permit.
a) ‘Class A’ bingo permit fee - $ .00
b) ‘Class B’ bingo permit fee - $ .00 per day (maximum of ten consecutive days)
c) ‘Class C’ bingo permit fee - $ .00
Please Note:
Organizations applying for a Class B bingo permit need to understand that due to the
nature of the activity to be conducted (a special event bingo game), the member in charge
of the organization may be required to attend a pre-bingo meeting as a prerequisite of
obtaining a permit.
Timely submittal of applications for bingo permits is imperative. Applications should be
submitted at least ten days prior to the date of an event in order to provide enough time
for the processing and issuance of a permit.
INSTRUCTIONS FOR COMPLETION OF THE BINGO APPLICATION
SUPPLEMENTAL FORM AND RELATED INFORMATION
1. Print the seven (7) digit organization Identification Number previously assigned.
2. Clearly print the complete name (first, middle, last) of the designated Member In Charge,
and provide a home and work telephone number where we may reach this individual, if
necessary.
3. The designated Member In Charge must sign his/her name and date the form in the space
provided in order to signify that he/she has read the Bingo law and the administrative
regulations governing Bingo, and understands he/she will be responsible for conducting
Bingo in accordance with the terms of the permit and the provisions of the Bingo law and
administrative regulations.
4. Provide the time (including a.m. or p.m.) the doors open to the public.
5. Provide the time (including a.m. or p.m.) the sale of cards or sheets begin.
6. Provide the time (including a.m. or p.m.) balls will be drawn for the bonanza game (if
any).
7. Provide the time (including a.m. or p.m.) the bingo games will commence.
8. Provide the complete checking account number of the sponsoring organization’s “Special
Bingo Bank Account”, if applying for a ‘Class A’ or ‘Class C’ bingo permit.
9. In the space provided, staple a voided (not cancelled) check from the sponsoring
organization’s “Special Bingo Bank Account”, if applying for a ‘Class A’ or ‘Class C’
bingo permit.
10. Attach one original identifiable admission card, sheet or ticket.
INSTRUCTIONS FOR COMPLETION OF THE BINGO PRICE SHEET
Complete the Bingo Price Sheet in duplicate. The name and address of the sponsoring
organization must be printed on each page. This information must be listed exactly as it
was on the organization’s approved bingo registration. Page numbers should be printed
in the upper left-hand corner of each page. The Organization I.D. # and the type of
permit (BA, BB, BM) should be printed in the upper right-hand corner of each page.
Identifiable admission: Provide information regarding the identifiable admission card,
sheet or ticket that each player is required to have at an authorized bingo game. Simply
provide the color and type of identifiable admission card, sheet or ticket, the number of
faces and sheets (if any), and the cost (if any) in the spaces provided.
Package sales: A “regular game” package is simply listed as a “package”. Acceptable
special game packages are as follows: “early bird package”, “special package”, or
“quickie package”. Package colors must be listed in the order that they are played, and
the number of sheets must equal the number of colors available. Every sheet must be
identified as a border, solid, tint, shaded or striped. The exceptions to this rule are “pre-
printed” or “tear-open” sheets, but a color still needs to be mentioned. Any color that is
also available separately must be noted. Please Note: Bingo cards or sheets must be
sold at a uniform unit price, and when a specific colored sheet is sold for a
particular game or games, that same color may not be used again during the same
bingo session. For example: A package contains a 3 face red border and there is also a 1
face red border listed as a special. This is not allowed.
Individual sales: These must be listed in the order that they are to be played, and
numbered accordingly. These games must be identified as “special”, “bonanza”,
“quickie”, “early bird, “50/50”, “WTA”, and “progressive” games. If a game is also sold
in a package, it must be noted accordingly.
Minimum required admission: The first line must contain information regarding the
identifiable admission card, sheet or ticket. If there are any packages or special games
the organization requires each patron to purchase, they must be listed on the lines below
the identifiable admission information.
Member In Charge: Both copies of the Bingo Price Sheet must be signed and dated by
the designated Member In Charge. Keep one copy for the organization’s internal records,
and attach one of the signed and dated copies to the application for the permit.
Page 2
Instructions for Completion of the Bingo Price Sheet
Amendments: If any information must be changed after the Bingo Price Sheet has been
approved as part of the organization’s application, an Application to Amend – Bingo
must be completed and submitted for consideration of approval. The last original price
sheet that was approved must also be submitted with the desired changes noted in yellow
highlight or in red or blue ink, and it must contain the original signature of the member in
charge and the current date. Changes may not be implemented prior to receiving an
approved amend form, aside from one exception; paper colors may be changed on the
Bingo Price Sheet without an approved amendment to the permit. All other changes
require approval.
INSTRUCTIONS FOR COMPLETION OF THE BINGO PRIZE SHEET
Complete the Bingo Prize Sheet in duplicate. The name and address of the sponsoring
organization must be printed on each page. This information must be listed exactly as it
was on the organization’s approved bingo registration. Page numbers should be printed
in the upper left-hand corner of each page. The Organization I.D. # and type of permit
(BA, BB, BM) should be printed in the upper right-hand corner of each page.
In order to complete the Bingo Prize Sheet, first list each game number to be played.
An organization may play a minimum of 15 games or a maximum of 40 games per
permitted bingo session. Please bear in mind that a multiple-part Winner-Take-All
game (WTA) is considered only RQHJDPH. On the prize sheet, a WTA game is a RQH-
OLQHentry, where the winning arrangement must be listed as “Caller’s Choice” and
the prize must be listed as “TBA”. Only two WTA games are allowed per bingo
session.
Print the name of the game in the “Game Description Type” column for all games other
than regular bingo games.
For each game, print the number of faces, the color of the sheet and the type (border,
solid, tint, shaded, sealed, pre-printed or striped) to be used in the “Number of Faces per
Cards/Sheets and Color” column.
A winning arrangement must be provided for each game played. Please bear in mind that
“To Be Announced” (TBA) is not allowed as an acceptable winning arrangement.
“Callers Choice” is acceptable as a winning arrangement only for WTA games.
List the prize amounts for each game while keeping in mind the allowable prize limits for
each type of game to be conducted.
o Regular game prizes – Prizes may be up to $200 each.
o Special game prizes – Prizes may range from $201 up to $750 each, provided
that the total doesn’t exceed $2,500 on any one day.
o Special Grand Prize – The rollover amount for a Special Grand Prize may not
exceed $500, and the maximum prize that may accumulate for up to sixteen
weeks is $5,000.
o Winner-Take-All (WTA) Game Prizes – Ninety percent (90%) of all receipts
from the sale of bingo cards for the WTA game or series of games must be
awarded as prizes, and each prize awarded may not exceed $500 in value.
If there are different prize schedules based on attendance, the column headings should be
listed as in the following example:
Prizes Prizes Prizes
80 or More 79 – 70 69 or Less
Players Players Players
Page 2
Instructions for Completion of the Bingo Prize Sheet
If the last attendance column has an ending number of players instead of the words “or
less”, the following statement must appear on the last line of the prize sheet: Bingo will
be cancelled if attendance is ## or less. Example:
Prizes Prizes Prizes
80 or More 79 – 70 69 – 50
Players Players Players
Bingo will be cancelled if attendance is 49 or less.
A maximum of two progressive games are allowed per session. If conducting a
progressive game, certain wording is required to be listed on the line(s) below the
progressive game information. The name of the winning arrangement and the words “in
?#’s or less wins jackpot, plus game prize” must be listed, along with the special grand
prize/rollover amount, as in the following example:
*cover all in ?#’s or less wins jackpot, plus game prize.
*special grand prize/rollover amount $500.00
If your organization intends to conduct a 50/50 game, a maximum payout amount must
be listed, as in the following example:
“50/50 max. $75.00”
Both copies of the Bingo Prize Sheet must be signed and dated by the designated
Member In Charge. Keep one copy for the organization’s internal records, and attach one
of the signed and dated copies to the application for the permit.
If any information must be changed after the Bingo Prize Sheet has been approved as part
of the organization’s application, an Application to Amend – Bingo must be completed
and submitted for consideration of approval. The last original prize sheet that was
approved must be also be submitted with the desired changes noted in either red or blue
ink, and it must contain the original signature of the member in charge. Changes may
not be implemented prior to receiving an approved amend form, aside from two
exceptions. Winning arrangements and paper colors may be changed on the Bingo Prize
Sheet without an approved amendment to the permit. All other changes require
approval.
IMPORTANT INFORMATION
Please Remember:
A winner-take-all game (WTA) is the ONLY game that can be played in parts. The
progressive jackpot game must say “JACKPOT, PLUS GAME PRIZE”. The game prize
must be paid with the jackpot! Example: If the jackpot is worth $2,000.00, the winner will
receive $2,100.00 ($2,000.00 plus the game prize of $100.00).
In the event an admission coupon or ticket is part of an admission package, the price of
the admission coupon or ticket, if any, must be noted separately.
ONCE A BINGO PERMIT HAS BEEN ISSUED, AN “APPLICATION TO AMEND”
MUST BE APPROVED BEFORE ANY CHANGE CAN TAKE PLACE!
Please Note: Bingo cards or sheets must be sold at a uniform unit price, and when a specific
color sheet with the same number of faces is sold for a particular game or games, that same
color sheet with the same number of faces may not be sold again during the same bingo
occasion or session. Also, you may change the color of your sheets without having to file an
Application to Amend – Bingo; however, if you are going to change the price of admission,
sheets of paper, or add or delete any games, you must submit and receive an approved
amendment application before any changes can be implemented. Each organization
desiring to amend the price of admission, sheets of paper, the number of games being
played or change its bingo prizes or pricing must provide an Application to Amend -
Bingo form, and a copy of the approved bingo prize and/or price sheet(s) with the
desired change(s) marked in red or blue ink. In addition, each prize or price sheet
submitted with changes must be signed by the bingo member in charge.
Organizations applying for a Class B bingo permit need to understand that due to the
nature of the activity to be conducted (a special event bingo game), the member in
charge of the organization may be required to attend a pre-bingo meeting as a
prerequisite to obtaining a permit.
TIMELY SUBMITTAL OF APPLICATIONS FOR BINGO PERMITS IS
IMPERATIVE. APPLICATIONS SHOULD BE SUBMITTED AT LEAST TEN DAYS
PRIOR TO THE DATE OF AN EVENT IN ORDER TO PROVIDE ENOUGH TIME
FOR THE PROCESSING AND ISSUANCE OF A PERMIT.
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APPLICATION FOR PERMIT TO CONDUCT BINGO CHARITABLE GAMES (Town of Somers)

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Completed 16 July 2020

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