Bingo Manufacturer And Distributor License Application Form - Department Of Inspections And Permits - Anne Arundel County Maryland

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Licensing Division, MS 6006
Department of Inspections and Permits
2664 Riva Road, Annapolis, MD 21401
Telephone: (410) 222-7788
Fax: (410) 222-4488
APPLICATION FOR A MANUFACTURER’S AND DISTRIBUTOR’S LICENSE
(Please type or print clearly)
A license is required for any person who manufacturers, sells, leases, or otherwise provides or
distributes bingo equipment or supplies to commercial bingo license holders. The annual license
fee is $2,000.00.
1. _________________________________________ ________________________________
Full Name of Applicant
Telephone Number
___________________________________________________________________________
Mailing Address
_________________________________________ ________________________________
FAX Number
E-Mail
a. The applicant is a ___partnership ___individual ___corporation ___other:___________
b. State or other jurisdiction of incorporation or organization _________________________
c. Federal Employer Identification Number _______________________________________
2. If you are a corporation, specify the name, date of birth, address, and title of each officer,
director and shareholder having a 10 percent interest or more. All other applicants must
specify the name, date of birth, and address of all owners. Attach additional sheets if more
space is necessary.
NAME & TITLE
DATE OF BIRTH
ADDRESS
_________________________
_______________
______________________________
_________________________
_______________
______________________________
_________________________
_______________
______________________________
MARYLAND RESIDENT AGENT
DATE OF BIRTH
ADDRESS
_________________________
_______________
______________________________
______________________________
Applicant’s Maryland Sales and Use Tax Account Number ______________________________
Applicant’s Maryland Personal Property Tax Account Number ___________________________
3. Attach a list of the equipment or supplies that will be offered to the commercial bingo
licensees. You may attach a catalog of equipment and supplies in lieu of a list.
4. List any electronic equipment that you provide to customers. Provide a sample of all reports
that each product generates.
5. Attach a list of the names and addresses of each location operated by the applicant.
(Continued on reverse)

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