Form Et 388md - Application For Manufacturer'S & Distributor'S License For Bingo And/or Raffle Equipment In Arkansas - 2008
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1
2STATE OF ARKANSAS
DEPARTMENT OF FINANCE AND ADMINISTRATION
APPLICATION FOR MANUFACTURER’S & DISTRIBUTOR’S LICENSE FOR
BINGO AND/OR RAFFLE EQUIPMENT IN ARKANSAS
Class Code 5101
Type of License:
(check the appropriate box)
Original
Renewal*
A. $2,500.00 Manufacturer’s License………………………..……………………………....………………
B. $2,500.00 Distributor’s License ………………………………....……………………………….............
*If renewal of $2,500.00 license, list current permit #: ________________
Name of Organization: ___________________________________________________ FEIN_____-_______________________
Contact person: __________________________________
Email: ________________________________________________
Telephone number: (
) ________ - ______________
Fax number: (
) _________ - ______________
Ownership type:
Corporation
LLC
Individual
LLC
Partnership
S-corporation
_______________________________________________________________________________________________________
Name of Owner/Officer/Partner
Title
_______________________________________________________________________________________________________
Name of Owner/Officer/Partner
Title
_______________________________________________________________________________________________________
Name of Owner/Officer/Partner
Title
1) Mail-to address (address to which forms/correspondence will be mailed)
_______________________________________________________________________________________________________
(
Street address / P.O. Box)
(City)
(State)
(Zip code)
2) Accounting records address (address of where Bingo/Raffle records will be maintained for inspection and audit)
_______________________________________________________________________________________________________
(
Street address)
(City)
(County)
(State)
(Zip code)
Official Use Only
Official Use Only
Official Use Only:
Status: Approved / Denied
Permit No. _________________
Check number: ____________________
Reviewer:____________________________
Permit duration
Check date:
____________________
From: ______/_______/______
Date: _______/________/________
Check amt:
$____________________
To: ______/_______/______
ET 388MD – Arkansas Bingo/Raffle License Application and Certification
(Revised 5/08)
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