Gc/bc Form 105 - Schedule C - Corporation Statement - Nys Gaming Commission - Division Of Charitable Gaming

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Division of Charitable Gaming
GC/BC FORM 105 – Schedule C
Corporation Statement
Corporation Name: _________________________________________________________________________________
__________________________________________________________________________________________________
METHOD OF INCORPORATION (check the appropriate box)
Filed a Certificate or Article of Incorporation or Charter
Granted by: __________________________________________ In the State of __________ on ____/____/____
(Title of Public Official or Agency)
Act of Legislative Body _______________________________ Number of Law ____________ Year __________
(State Legislative Body)
Foreign Corporation ____ yes ____ no
Have you filed an Application for Authority to conduct business in New York State? ____ yes ____ no
(If so, please provide a copy with your application.)
Person in this state who is authorized to produce records and supply information on your company’s behalf:
___________________________ _____________________ ______________ __________ _________ ______________
Name
Street Address
City
State
Zip Code
Title
__________________________________________________________________________________________________
Has the corporation filed Federal Tax Returns? ____ yes ____ no Where? ______________________________________
(Please provide a copy of your most recent tax return)
__________________________________________________________________________________________________
List names, titles, addresses and compensation of all officers and directors.
(If necessary use a separate sheet of paper)
Name
Street Address
City
State Zip Code
Title
Compensation
___________________ _____________________ ____________ ______ ________ _____________ $______________
___________________ _____________________ ____________ ______ ________ _____________ $______________
___________________ _____________________ ____________ ______ ________ _____________ $______________
___________________ _____________________ ____________ ______ ________ _____________ $______________
___________________ _____________________ ____________ ______ ________ _____________ $______________
List names, addresses and compensation of all employees.
(If necessary use a separate sheet of paper)
Name
Street Address
City
State Zip Code
Title
Compensation
___________________ _____________________ ____________ ______ ________ _____________ $______________
___________________ _____________________ ____________ ______ ________ _____________ $______________
___________________ _____________________ ____________ ______ ________ _____________ $______________
___________________ _____________________ ____________ ______ ________ _____________ $______________
___________________ _____________________ ____________ ______ ________ _____________ $______________
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Form 105 (Rev. 1/2016)

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