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Form Et 388md - Application For Manufacturer'S & Distributor'S License For Bingo And/or Raffle Equipment In Arkansas - 2008 Page 2

Responsible Person Certification

The Responsible Person within the organization shall meet the following requirements:

The responsible person shall not have been found guilty of or pleaded guilty or no contest to:

a. Any felony by any court in the State of Arkansas; or

b. Any similar offense by a court in another state or of any similar offense by a military or federal

court.

I, _____________________________________________________ certify that as the responsible person

(Print name)

for ______________________________________, that I have not been found guilty or pleaded guilty to a

(Name of organization)

felony in the State of Arkansas, another state, or in a military or federal court.

_______________________________________

_______/________/________

(Signature of responsible person)

Date

I certify that as the authorized agent of the applying organization that all information on the face of this document, schedules, and

supporting documents are true and correct to the best of my knowledge. I further attest to the fact that I have received a copy of

the Rule 2007-4, as they pertain to this application and the operation of charitable bingo games and raffles in Arkansas, and that I

will abide by such Rules.

_________________________________________________

_______/________/________

(Signature of agent of applying organization)

(Date)

Mail or bring completed license application and fee to: Department of Finance and Administration

Miscellaneous Tax Section

P.O. Box 896, Room 2340

Little Rock, AR 72203-0896

Office phone (501) 682-7187

ET 388MD – Arkansas Bingo/Raffle License Application and Certification

(Revised 5/2008)

Form Et 388md - Application For Manufacturer'S & Distributor'S License For Bingo And/or Raffle Equipment In Arkansas - 2008 Page 2