Looking for a New York State Legal Forms And Templates? Download it for free!

Division of Charitable Gaming

GC/BC FORM 106

Supplier License Application For

Manufacturing or Distributing

Games of Chance and/or Bingo Supplies

and Equipment

1. Business Name: __________________________________________

License Number: _____________________

Business Phone Number: __________________________

Business Fax Number: ________________________

Business Address: _____________________________________

Web Address: __________________________

2. Does your business have a “d/b/a”, Division or Subsidiary? _____ yes or _____ no

If “yes”, state name(s):___________________________________________________________________________

Indicate all subsidiaries doing business in New York, if any: _____________________________________________

3. Contact Person: ________________________________ ____________________________

Name

Title

Phone Number: ______________________

E-Mail Address: _________________________

4 (a) Indicate which license you are applying for: ____ Games of Chance ____ Bingo ____ Both

(b) Indicate the type of company you are? ____ Manufacturer ____ Distributor

5. Indicate all types of activities your company will be performing during the license period: ______________________

_______________________________________________________________________________________________

6. Indicate all addresses where your company’s games of chance and/or bingo supplies, equipment and business records

are kept (in your state and out of state): _______________________________________________________________

7. What other states or countries does your company hold licenses in?_______________________________________

(

Attach a copy of your most recent license obtained in each state and country.)

8. (a) Has any officer, director, agent or employee ever been charged with a criminal violation of any games of chance

and/or bingo matters? _____ yes or _____ no

If yes, provide details on a separate sheet of paper.

(b) Has the applicant ever been the subject of any administrative proceedings involving games of chance and/or

bingo violations? _____ yes or _____no If yes, provide details on a separate sheet of paper.

9. Has the applicant ever sold games of chance and/or bingo supplies and equipment under any other name(s)?

_____ yes or _____ no If yes, list the name(s) on a separate sheet of paper.

10. Has the applicant or (if a partnership) any of the partners or (if a corporation) any of the officers, directors or

stockholders ever been knowingly engaged in business with a professional gambler, gambling promoter or

convicted criminal? _____ yes or _____ no If yes, provide details on a separate sheet of paper.

11. (a) Does your company provide gambling supplies and equipment and/or personnel for entertainment nights/games

of chance and/or bingo? _____ yes or _____ no If yes, provide details on a separate sheet of paper.

(b) Has your company received a percentage of the gaming proceeds from such entertainment nights/games of

chance and/or bingo not including the rental of such equipment? _____ yes or _____ no

12. If the applicant is a distributor, indicate the name(s) of the manufacturing companies from whom you will be

purchasing your games of chance and/or bingo supplies and equipment:

___________________________________________________________________________________

Page 1 of 2

Form 106 (Rev. 4/2015)

Gc/bc Form 106 - Application For Games Of Chance And/or Bingo Supplier'S License - Nys Gaming Commission - Division Of Charitable Gaming

Related Articles

Related forms

Related Categories