Fill - Free fillable Bingo License Application (Township of Long Hill) PDF form

Application No. BA _________________

Identication No. __________________

New Jersey Ofce of the Attorney General

Division of Consumer Affairs

Legalized Games of Chance Control Commission

124 Halsey Street, 6th Floor, P.O. Box 46000

Newark, New Jersey 07101

(973) 273-8000

Application for a Bingo License

Submit four (4) copies of this application to the Municipal Clerk’s ofce in the municipality where the games will be conducted.

Please print clearly.

Name of municipality: ____________________________________________________________________________________

Part A - General

1. Name of applying organization: _________________________________________________________________________

2a. Street address of headquarters: __________________________________________________________________________

b. Mailing address (if different):

3. List date(s) and hours for games:

Date Hours Date Hours

____________________________ __________ ____________________________ __________

4. Address of place where bingo will be played:

a. Does the applicant own the premises or regularly occupy them for its general purposes? Yes No

b. If “No,” from whom will the applicant rent the premises?

Name _________________________________________Address _______________________________________________

c. If premises are to be rented, attach Form 10, “Statement of Landlord.”

Part B - Schedule of Expenses

The items of expense intended to be incurred or paid in connection with the games listed in this application, the names and

addresses of the persons to whom each item is to be paid, and the purpose for which each item is to be paid, are:

Item of Expense Name and address of supplier Purpose

__________________________ ________________________________________________ ________________________

Rev. 4/16

Part C - Schedule of Purposes

1. The specic purpose(s) to which the entire net proceeds of the games listed in this application are to be devoted, and the

manner in which they are to be so devoted, are:

2. If any part of the net proceeds are to be devoted to a purpose allowed by the Bingo Licensing Law by turning the same

over to another organization which is exclusively devoted to such purposes, secure the signature of its president or other

executive ofcer to the following certicate:

“It is hereby certied that ________________________________________________________________________________

Name of organization

will accept from the licensee any part of the net proceeds of the games listed in this application to be turned over to it.”

Date: __________________________________ Signature: ___________________________________________

Part D - Schedule of Prizes

A description of all prizes to be offered and given in all of the games listed in this application is as follows. (For cash prizes,

state the amount; for merchandise, describe the article and state the retail value; if prizes are to be donated, indicate that fact

and estimate as accurately as possible the information requested below.)

Description of Prize Amount (for cash prizes) or Article Retail value

(Additionally, please attach a schedule of the games to be conducted.)

_______________________________________________________________________ __________________________

click to sign

signature

click to edit

Part E - Ofcers of Applicant

Ofce Name of ofcer Residence address Age

__________________________ _______________________________ _____________________________________ _____

Part F - Members of Applicant who will be in charge of the games

Name of member in charge Residence address Telephone No. Age

(include area code)

_____________________________ _________________________________________ ________________________ _____

Part G - Members of Applicant who will assist in conducting the games

Name of member Residence address Age

________________________________________ ________________________________________________________ _____

Part H - Names of other organizations whose members will assist in conducting the games

Name and address of organization How related Identication No.

______________________________________________________ ___________________________ ____________________

continue ➨

If more space is needed in any section of this application, insert extra sheets of paper.

Part I - Statement of Applicant and member(s) in charge

State of New Jersey

County of __________________________________

We do hereby each make the following statement, under oath, with respect to the foregoing application:

____________________________________________________

Signature of Ofcer and Title

____________________________________________________

Signature of Member-in-Charge

____________________________________________________

Signature of Member-in-Charge

____________________________________________________

Signature of Member-in-Charge

____________________________________________________

Signature of Member-in-Charge

If more space is needed in any section of this application, insert extra sheets of paper.

Applicant’s registration slip from the Legalized Games of Chance Control Commission

must be presented to the Municipal Clerk with this application.

Sworn and subscribed to before me this

______day of ________________ , 20 ___.

____________________________________

Notary Public (Print name)

____________________________________

Signature of Notary Public

Affix seAl here

1. The applicant (is) (is not) limited in its activities to the

furtherance of one or more authorized purposes as dened

in the Bingo Licensing Law.

2. Prior to the issuance of any license to it to conduct games

of chance, the applicant was actively engaged in serving

one or more “authorized purposes.”

3. The applicant has received and used, and in good faith

expects to continue to receive and use, to further one or

more authorized purposes, funds from sources other than

games of chance.

4. The conduct of the games on the occasion or occasions for

which this application is made will be to raise and devote

the entire net proceeds to the authorized purpose described

in the application.

5. For each occasion for which a license is sought, one or more of

the members listed who are familiar with the Bingo Licensing

Law and the Rules and Regulations, will be in full charge of,

and primarily responsible for, the conduct of the games.

6. No commission, salary, compensation, reward or recompense

will be paid to any person for holding, operating or conducting

or assisting in the holding, operation or conducting, of the

games, except to bookkeepers or accountants for professional

services not exceeding the amounts xed by the Schedule

of Fees, as well as the compensation for the Licensed

Compensated Workers pursuant to N.J.A.C. 13:47-6A. All

prizes offered for games conducted on a single occasion will

not exceed the limit on the sum or retail value of prizes as

provided by the Bingo Licensing Law (N.J.S.A. 5:8-25 et seq.)

and N.J.A.C. 13:47-6.16 and 13:47-7.2.

7. All statements in the foregoing application are true.

} ss.

click to sign

signature

click to edit

click to sign

signature

click to edit

click to sign

signature

click to edit

click to sign

signature

click to edit

click to sign

signature

click to edit

click to sign

signature

click to edit

Download
Save PDF to desktop

Email
Email completed PDF

Send for Signing
Email for others to sign

Print
Print document

NAME

Bingo License Application (Township of Long Hill)

View Audit Log
Print With Audit Log
Duplicate Document

Fill Online, Printable, Fillable, Blank Bingo License Application (Township of Long Hill) Form

Related forms

Fillable Bingo License Application (Township of Long Hill)

Fill Online, Printable, Fillable, Blank Bingo License Application (Township of Long Hill) Form

Related forms

First 20 documents completely FREE!