Cg-3 State Form 45382 - Single Event License Application - 2005
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1
2
3
4For Official Use Only
License Fee Paid
Indiana Department of Revenue
Form CG-3
Date Received
State Form 45382
Reviewed By
Single Event License Application
Date Reviewed
(R3/7-05)
Date Keyed
You must file this application at least eight (8) weeks before your scheduled event.
Check only one box per application:
Special Bingo License
Charity Game Night License
Raffle License
Annual Door Prize License*
Festival License
Door Prize License
Calendar Raffle*
Water Raffle License
*(You must attach a calendar or a list of drawing days.)
1. Name of Organization (please type or print)
Taxpayer Identification Number (TID)
2. Previous Name of Organization (if name changed)
Federal Identification Number (FID)
3. DBA (Doing Business As) Name
Contact Person
Contact Person's Phone Number
4. Street Address of Principal Office (as it appears on the Charity Gaming Qualification Application, Form CG-1)
City
State
Zip Code
County
Daytime Telephone Number
Office Business Hours
(
)
5. On what date(s) and during what hours will your special event be conducted? (a.m. establishes the midnight hour, p.m. establishes the noon
hour.) (Except festivals, sessions can run no more than 8 consecutive hours.)
Calendar Raffles or Annual Door Prize Only:
Date
Hours
M
to
M
First Drawing Date:
Festivals Only:
Last Drawing Date:
Date
Hours
M
to
M
Drawing Hours:
M to
M
Date
Hours
M
to
M
FOR OFFICE USE ONLY
Date
Hours
M
to
M
Date
Hours
M
to
M
6. Street address of the facility where the gaming event will be conducted.
OR, on what body of water are you going to hold a water raffle event?
City
State
Zip Code
County
Daytime Telephone Number
(
)
Attach additional sheets, if necessary,
Lessee/Ownership
to supply all information for each line.
7. Does your organization own _____, lease (rent) _____, or use a donated _____ facility where the licensed event will be conducted? (Check one)
If leased (rented), enter name and address of lessor and attach a copy of your signed lease agreement.
If donated, attach a notarized statement from the donor that the facility is being offered rent free.
NOTE: Check this box
if the rented facility is being used for an annual convention or other yearly meeting of your organization's (or your
affiliate's) membership.
Name of Lessor (Full legal name)
Address
City
State
Zip Code
County
Daytime Telephone Number
(
)
CG-3 (1)
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