Cg-2 Form 45381 - Annual Bingo And/or Pull Tab Application (First Time Applicants)
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4For Official Use Only
Indiana Department of Revenue
CG-2
License Fee Paid
State Form 45381
Annual Bingo and/or Pull Tab Application
Date Received
(R2/7-05)
Reviewed By
For First Time Applicants
Date Entered
Processing of this application can take up to 120 days.
1. Name of Organization (Please type or print)
2. Indiana Taxpayer Identification Number (TID)
3. Previous Name of Organization (If name changed)
4. Federal Identification Number (FID)
5. Street Address of Principal Office (As it appears on the Charity Gaming Qualification Application, Form CG-1)
Business Hours
City
State
Zip Code
County
Daytime Telephone Number
(
)
6. On which days of the week and during what hours will your bingo event be conducted? (a.m. establishes the midnight hour, p.m. establishes the
noon hour). (Time is limited to no more than 8 consecutive hours per session).
Day __________ Hours _______ __M to _______ __M
Day __________ Hours _______ __M to _______ __M
Check this box if you wish to sell pull tabs, punchboards, and tip
Day __________ Hours _______ __M to _______ __M
boards only, and not play bingo. (Also complete Lines 7 through 28).
7. Street address of the facility where the bingo and/or pull tab event will be conducted and the DBA name (Doing Business As), if applicable.
City
State
Zip Code
County
Daytime Telephone Number
(
)
Attach additional sheets if necessary
Leasing Information
to supply all information for each line.
8. 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, enter name and address of donor and attach a notarized statement from the donor that the facility is being offered rent free.
Name of Lessor/Donor (Full legal name)
Address
City
State
Zip Code
County
Daytime Telephone Number
(
)
9. Is any tangible personal property (i.e. tables, chairs, bingo blowers, etc.) being leased or donated to you for this event?
Yes
No
If you answered Yes, list the name and address of the lessor or donor. Attach a signed copy of the lease agreement or donation statement from
the donor. Note: Bingo equipment must come from a licensed distributor and/or manufacturer.
Name
Address
City
State
Zip Code
10. Does your organization own bingo equipment?
Yes
No
If you answered Yes, list the distributor/manufacturer's name, date of purchase, purchase price, and type of equipment purchased.
If you answered No, provide information on the distributor/manufacturer where equipment will be purchased.
Name of Distributor/Manufacturer
Date of Purchase
Purchase Price
Equipment Type
CG-2 (1)
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