APPLICATION FOR PERSONAL
IDENTIFICATION NUMBER
(P.I.N.) BINGO
INSTRUCTIONS:
1. Print or type.
2.
Complete and attach Notice and Statement of Applicant.
3.
Mail application forms to: Meriden Police Department Records, 50 West Main St., Meriden, CT 06451
4. A Personal Identification Number (P.I.N.) will be issued upon approval.
TO:
P.I.N.
NAME OF APPLICANT (Last) (First) (Middle) SOCIAL SECURITY NUMBER
- -
ADDRESS OF APPLICANT (No. and Street) (City or Town) (State) (Zip Code)
TELEPHONE NUMBER
HOW LONG AT
PRESENT ADDRESS?
PREVIOUS ADDRESS (No. and Street) (City or Town) (State) (Zip Code)
DATE OF BIRTH
(Mo.) (Day) (Yr.)
PLACE OF BIRTH SEX
M F
HEIGHT WEIGHT
Have you EVER been convicted of any crime, felony, misdemeanor,
disorderly persons offense or other offense other than a traffic violation?
YES NO
IF “YES”, GIVE DETAILS:
ORGANIZATION REPRESENTED (Name) (No. and Street) (City or Town) (State) (Zip Code)
ORGANIZATION’S IDENTIFICATION NUMBER
HOW LONG HAVE YOU BEEN A BONAFIDE MEMBER OF ORGANIZATION?
Please specify in terms of years or months.
YEARS MONTHS
Have you ever applied for a P.I.N. to operate bingo games for any other organization?
YES NO
IF “YES”, GIVE DETAILS: (Organization Name) (No. and Street) (City or Town) (State) (Zip Code) ASSIGNED P.I.N.
APPLICANT’S SIGNATURE (Please sign with blue or black ink only)
DATE
(Mo., Day, Yr.)
I hereby certify that the above named applicant is a bonafide member of the represented organization.
SIGNATURE OF ORGANIZATION RANKING OFFICER (Note: The applicant may not sign as an officer)
DATE
(Mo., Day, Yr.)
DO NOT WRITE BELOW THIS LINE
APPLICATION FOR P.I.N. IS APPROVED
DATE (Mo., Day, Yr.)
NOTICE AND STATEMENT
OF APPLICANT
INSTRUCTIONS:
1. Please sign this form in the two areas provided below.
2.
Mail form to: Meriden Police Department Records, 50 West Main St., Meriden, CT 06451
NOTICE
The purpose of this notice is to advise that applications for regitrations/permits are
individually checked for convictions of any crime other than traffic violations.
Your failure to truthfull y disclose any such convictions, either for yourself or your spouse may
result in the denial of your application for registrations/permits.
Similarly, y our failure to provide all of the details of ANY conviction, such as the date of the
conviction, the offense of which you were convicted, the court location where you were
convicted and the disposition made by the court location where you were convicted and the
disposition made by the court in your case – i.e., 30 days - $50.00 fine, probation, etc. will also be
cause for denial of the registration/permit.
In addition, any falsification or untruthful answer to any other question on the application may
result in a denial of the registration/permit.
Please sign this form where indicated below.
I hereby acknowledge that I have read the foregoing notice.
Printed Name of Applicant
Signature of Applicant
Date
STATEMENT OF APPLICANT
BY THE ACCEPTANCE OF ANY REGISTRATION/PERMIT issued pursuant to this application:
I agree to abide by the applicable Regulations .
I HEREBY CERTIFY that I have read the foregoing application and affirm that every statement
contained therein is TRUE, COMPLETE AND CORRECT. I understand that if I misstate or omit
any fact, I am subject to the penalties provided by la w and by the above-mentioned applicable
regulations.
I HEREBY AUTHORIZE the Meriden Police Department to investigate any and all records
concerning my background,
including but not limited to any criminal convictions. I
FULLY UNDERSTAND the preceding WAIVER.
Printed Name of Applicant
Signature of Applicant
Date
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