Revised 1/2017
Staff Use Only
City of Wildwood, Florida
Development Services Department
Fee Paid:
100 N. Main St., Wildwood, FL 34785
Method of Payment:
Tel: 352.330.1334 Fax: 352.330.1338
www.wildwood-fl.gov
Permit Number:
Class A Bingo Permit - for Charity Bingo Operators
Review Ordinance Number O2014-31 Wildwood Bingo Ordinance as amended (O2015-12) for a list of rules/regulations/requirements
regarding bingo permits prior to submitting an application.
Contact Information (Please print legibly):
Bingo Operator(s)/ Charity Name:
Address:
Phone: Email:
Property Owner / Lessor Name:
Address:
Phone: Email:
Site Information:
Property Address:
Parcel Number(s): Dimensions of Property:
Existing Zoning: Design District:
ITEMS REQUIRED AT THE TIME OF APPLICATION
$100.00 non-refundable application fee; waived for certain entities listed below created pursuant to law. For the three entities listed
below, provide the following ONLY: Application, List of Operators, and days / hours of operation.
Condominium Association Cooperative Association Mobile Home Park
Complete list of all Operators (and the operating document governing their business structure, if applicable).
A listing of the days of the week the Operator performs, conducts, or supervises bingo games. (A supplemental statement must be
filed with the City Manager prior to any schedule changes).
Detailed description of the charitable, civic, community, benevolent religious, or scholastic works in which the Operator is involved,
and the specific endeavors to which the proceeds from the bingo games shall be donated.
The names and addresses of all persons, firms, corporations, or business entities directly or indirectly owning more than ten percent
(10%) of the Bingo Operator.
A financial statement of the Bingo Operator, evidencing the amount and sources of the previous year's gross revenue and the
distributees with the amounts distributed. Statement must be certified correct, but may be unaudited.
List of phone numbers and contact information on-site.
By submitting this application, the undersigned acknowledges that no person shall make a false, untrue, or misleading oral statement to
any code enforcement officer, or any other City official, as to any matter investigated in relation to the provisions or enforcement of this
ordinance.
The undersigned certifies under oath and penalties of perjury, that the information provided herein is true and correct to the best of his/
her knowledge, and that any person who knowingly and willfully violates the terms of this ordinance, upon being found guilty, shall be
punished by a civil fine not to exceed $5,000.00 for each occurrence in addition to automatic revocation of their Bingo Permit. Each act
of violation and each day any violation shall occur shall constitute a separate offense.
Owner / Lessor Signature: Date:
NOTE: The application MUST be signed by the Charity Bingo Operator. For Corporations, Partnerships, Limited Liability Corporations, or other types
of business organization, appropriate authorization from the organization must be provided at the time of application.
click to sign
signature
click to edit
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