Sd Eform 1338 - Application For License To Distribute Bingo And Lottery Equipment And Supplies - South Dakota Department Of Revenue Page 4

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Application License To Distribute Bingo And Lottery Equipment And Supplies
Distributor Personnel Information -
All persons who complete the Distributor Personnel Information Form must include the complete name and
address of any organization which they conduct bingo games and lotteries of which they are members. If none
state so here. _______________
Organization _____________________________________________________ Office __________________
Address __________________________________________________________________________________
(street)
(city, state, zip)
Organization _____________________________________________________ Office __________________
Address __________________________________________________________________________________
(street)
(city, state, zip)
Organization _____________________________________________________ Office __________________
Address __________________________________________________________________________________
(street)
(city, state, zip)
Organization _____________________________________________________ Office __________________
Address __________________________________________________________________________________
(street)
(city, state, zip)
Organization _____________________________________________________ Office __________________
Address __________________________________________________________________________________
(street)
(city, state, zip)
Organization _____________________________________________________ Office __________________
Address __________________________________________________________________________________
(street)
(city, state, zip)
Signature Block
I declare, under penalty of perjury, that the information, herein provided, is accurate and complete.
________________________________________________________________________________________
Signature
Date
Notes: Attach additional sheets as needed to answer any of the questions above. This form must be completed
by any owner, partner, officer, director, supervisor or manager of a bingo-lottery distributor licensee.
PRINT FOR MAILING
CLEAR FORM
1.

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