Bingo Manufacturer And Distributor License Application Form - Department Of Inspections And Permits - Anne Arundel County Maryland Page 2

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6. Attach evidence of workers compensation insurance or a certificate of compliance from the
Maryland Workers’ Compensation Commission.
7. Attach a completed disclosure statement for each person listed in Section 2 above.
8. Is the applicant licensed in other jurisdictions?
___Yes ___No
If you answered “yes” to the above question, please attach copies of those licenses, and
provide a name, telephone number, and mailing address for each jurisdiction. If you
answered no, the following information must be provided for each name given in
section 2.
a. A review by a certified public accountant of the personal financial background, including
a review of contingent or pledged liabilities.
b. An income statement for the most recent fiscal year.
c. The name address and telephone number of three professional or personal character
references.
On behalf of the aforementioned applicant under the penalty of perjury, I certify that all of the
statements in the reports, forms and attachments comprising this application are true to the best
of my knowledge. It is understood that this verification will be considered an integral part of the
application. It is further understood that if there is any change with respect to any of the facts
herein set forth, during the pendency of the application, such change must be reported to the
Department immediately by the undersigned. If any changes occur after the issuance of the
license applied for, such change must be reported to the Department in accordance with the
requirements of Article 11 of the Anne Arundel County Code and the ‘Commercial Bingo
Licensure and Operation Regulations.’ It is further understood that any false and/or incorrect
statements may result in proceedings to revoke, cancel or suspend such license.
_________________________________ __________________________ ________________
Signature
Title
Date
******************************************************************************
STATE OF ____________________________________________
COUNTY OF __________________________________________
_____________________________, being duly sworn, deposes and says he/she is the applicant
named above, or an officer of the corporation, or a member of the partnership in behalf of which
the application is made, that he/she has read the application and that the statements therein are
true to the best of his/her knowledge and belief.
Sworn to before me this ______________ day of _____________________, 20_____.
________________________________________
Notary Public
Manufacturer & distributor license app
Rev. Sept. 2009

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