Cg-2 Form 45381 - Annual Bingo And/or Pull Tab Application (First Time Applicants) (Page 4 of 4) in pdf

Cg-2 Form 45381 - Annual Bingo And/or Pull Tab Application (First Time Applicants) Page 4

Previous Charity Gaming License Information

24. Has your organization been previously licensed by the Indiana Department of Revenue to conduct annual bingo events?

Yes*

25. Has your organization ever had a prior charitable gaming application denied by the Indiana Department of Revenue or had its license suspended

or revoked?

Yes*

*If yes, list the reasons why your license was denied, suspended, or revoked.

____________________________________________________________________________________________________________

License Fee Information

26. The license fee for an organization's first Annual Bingo and/or Pull Tab License is $25.00 and must be paid with this application. The fee

should be paid by a check drawn from your nonprofit checking account. Make your check payable to: Indiana Department of Revenue.

27. Certification

We certify under penalty of perjury that the organization applying is a qualified organization, and there are no misrepresentations or

falsifications in the information stated. We understand false or misleading statements will cause rejection of this application or revocation of

future license(s). We attest that we reside in the same county where the licensed event will be held.

Contact Name

Phone Number

Signature of Officer

Officer's County of Residence

Date

Printed Name of Officer

Signature of Officer

Officer's County of Residence

Date

Printed Name of Officer

Send this application and $25.00 fee to:

Indiana Department of Revenue

Charity Gaming Section

100 N. Senate Avenue - Room N203

Indianapolis, IN 46204

Phone: (317) 232-4646

CG-2 (4)

Cg-2 Form 45381 - Annual Bingo And/or Pull Tab Application (First Time Applicants) Page 4