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 Ofcer 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.
1. The applicant (is) (is not) limited in its activities to the
furtherance of one or more authorized purposes as dened
in the Bingo Licensing Law or the Rafes Licensing Law.
2. Prior to the issuance of any license to it to conduct games
of chance the applicant was actively engaged in this State
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 or the Rafes Licensing Law, as the case may be, 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, 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. No
prize greater in amount or retail value than authorized by law
will be awarded in any single game.
7. All statements in the foregoing application are true.
Sworn and subscribed to before me this
______day of ________________ , 20 ___.
____________________________________
Notary Public (Print name)
____________________________________
Signature of Notary Public
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