INSTRUCTIONS:
1. Print or type. Attach payment of the $.00 registration fee, payable to "&LW\ RI 0HULGHQ
2. The completed application and fee must be mailed to: Meriden Police Department Records, 50 West Main St., Meriden CT 06451
3. An Identification Number will be issued upon approval.
TO:
IDENTIFICATION NUMBER (To be assigned)
NAME OF ORGANIZATION
TELEPHONE NUMBER
STREET ADDRESS (No. and Street) (City or Town) (State) (Zip Code)
MAILING ADDRESS (Name) (No. and Street) (City or Town) (State) (Zip Code)
LIST OF OFFICERS OF THE SPONSORING ORGANIZATION
NAME (Last, First, Middle) TITLE NAME (Last, First, Middle) TITLE
1. 4.
2. 5.
3. 6.
I, the undersigned ranking officer of subject organization, do hereby state
that all Bingo sessions operated by subject organization under this
registration will be conducted in compliance with the Connecticut General
Statutes and with all Administrative Regulations concerning Recreational
Bingo for Parent Teacher Associations.
SIGNED (Ranking Officer)
PRINTED NAME of Ranking Officer
DATE (Mo., Day, Yr.)
OATH
Personally appeared the signer of the foregoing statement and made oath before me to the matter contained herein.
SIGNED (Notary Public)
MY COMMISSION EXPIRES: DATE (Mo., Day, Yr.)
ATTEST
To the best of my knowledge and belief, information contained in this application is:
True and correct and subject orga
nization qualifies for and SHOULD be issued a registration and an Identification
Number.
Not true or correct and subject organization SHOULD NOT be issued a registration and an Identification Number.
COMMENTS
SIGNED (Chief of Police or First Selectman)
DATE (Mo., Day, Yr.)
APPLICATION FOR REGISTRATION AMUSEMENT &
RECREATION BINGO FOR A PARENT TEACHER ASSOCIATION
IS APPROVED
DATE (Mo., Day, Yr.)
APPLICATION FOR REGISTRATION
AMUSEMENT AND RECREATION BINGO
FOR PARENT TEACHER ASSOCIATIONS
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