INSTRUCTIONS:
1. Print or type.
2.
Mail application 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)
Does your organization consist of members sixty (60) years of age or older? YES NO
INDICATE DAY(S) OF WEEK AND HOURS OF BINGO OPERATION
1 SUNDAY
am
From: ____________pm
am
To: ____________pm
5 THURSDAY
am
From: ____________pm
am
To: ____________pm
2 MONDAY
am
From: ____________pm
am
To: ____________pm
6 FRIDAY
am
From: ____________pm
am
To: ____________pm
3 TUESDAY
am
From: ____________pm
am
To: ____________pm
7 SATURDAY
am
From: ____________pm
am
To: ____________pm
4
WEDNESDAY
am
From: ____________pm
am
To: ____________pm
ADDRESS WHERE BINGO WILL BE PLAYED (No. and Street) (City or
Town) (State) (Zip Code)
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 Connecticut General Statutes and with all
Administrative Regulations concerning Amusement and Recreation Bingo.
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
organization 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 AMUSEMENT AND RECREATION BINGO REGISTRATION IS APPROVED
DATE (Mo., Day, Yr.)
APPLICATION FOR REGISTRATION
AMUSEMENT AND RECREATION BINGO
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