Cg-2 Form 45381 - Annual Bingo And/or Pull Tab Application (First Time Applicants) Page 2
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4Operator and Worker Information
11. List below each bingo operator who will supervise, manage, and be responsible for the operation and conduct of the gaming event. Attach
additional sheets if necessary. Please type or print. Note: All operators, must be Indiana residents.
Name
Home Address
Social Security Date of Daytime Telephone Membership Member Bartender
(Street, City, State, Zip Code)
Number
Birth
Number
Years/Group
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12. Please list the name from Line 11 of the principal person in your organization who has overall responsibility for the operation and control of
this charity gaming event. Please type or print.
X
13. Are any of the operators listed on Line 11 also operators for any other organization's charitable gaming events? Yes
No
If yes, list
each individual's name, name of organization, and the month(s) that they will operate other gaming events. Attach additional sheets if
necessary.
14. List all individuals (excluding operator information on Line 11) who will assist and work in the operation of the licensed event. Attach additional
sheets if necessary. Please type or print. Note: All workers must be Indiana residents or meet the criteria prescribed under 45 IAC 18-1-43.
Name
Home Address
Social Security Date of Daytime Telephone
Membership Member Bartender
(Street, City, State, Zip Code)
Number
Birth
Number
Months or
Years/Group
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15. Have any operators or workers listed above, or on any attachments, been convicted of a felony in any jurisdiction? Yes
No
If you answered Yes, list each name and date of conviction. Attach additional sheets if necessary.
Concession Information
16a. Will concessions be offered during the licensed event? (Check one)
Yes
No
If Yes, complete the following information.
If the concessionaire is required to have a retail merchant certificate enter that number in the box provided.
Name of organization offering the concessions
Indiana Retail Merchant Certificate Number
16b. Which of the following will your organization be receiving? (Check one)
_____ All of the concession income
_____ A flat fee concession payment
_____ A percentage of the concession income
_____ Other (explain) ___________________________________________
CG-2 (2)
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