INSTRUCTIONS:
1. Print or type and, if necessary, use additional sheets. Have application notarized.
2.
The completed form must be mailed to:0HULGHQ3ROLFH'HSDUWPHQW5HFRUGV:HVW0DLQ6W0HULGHQ&7
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: $75.00)
DAY OF
WEEK: _______________ TIME: _______________ TO: _______________
CLASS B (Maximum of ten successive days) (Fee: $10.00 per day)
DATE: __________ TO: __________ TIME: __________ TO: __________
CLASS C (One day each month from issue date to 9/30) (Fee: $50.00)
-$1 ____/_____/____
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
INSTRUCTIONS:
1. Print or type, and attach all required material.
2.
The completed form must be mailed to: Meriden Police Department Records, 50 West Main St., Meriden, CT 06451
TO:
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 start:
SPECIAL BINGO BANK ACCOUNT (for Class A&C ONLY)
Account number:
Attach a voided (not cancelled) check from the special bingo bank account in the space provided below:
ATTACH VOIDED CHECK HERE
(please staple the check on the left edge of the paper)
ATTACHMENT
Attach one original
identifiable admission card, sheet or ticket. A photocopy is not acceptable.
BINGO SUPPLEMENTAL FORM
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