Initial Application Form For Bingo/raffle Equipment Providers, Instant Raffle Equipment Distributors/manufacturers, And Casino Night/armchair Race Equipment Providers - New Jersey Office Of The Attorney General

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New Jersey Office of the Attorney General
Division of Consumer Affairs
Legalized Games of Chance Control Commission
124 Halsey Street, P.O. Box 46000
Newark, N.J. 07101
(973) 273-8000
Initial Application for
Bingo/Raffle Equipment Providers,
Instant Raffle Equipment Distributors/Manufacturers, and
Casino Night/Armchair Race Equipment Providers
Along with this completed application please submit a nonrefundable, nontransferable application fee of $100 in
the form of a certified check or money order made payable to the Legalized Games of Chance Control Commission.
Once the applicant has been notified that its application has been approved by the Commission, the applicant
will be asked to submit a license fee of $1,000 for a bingo/raffle equipment provider or a casino night/armchair
race equipment provider, and $3,000 for an instant raffle equipment supplier, in the form of a certified check or money
order made payable to the Legalized Games of Chance Control Commission.
Please print clearly.
A. Applicant Information
(For all applicants, if additional space is needed attach a notarized addendum to this application.)
Specify type of business: Individual Corporation Partnership Association Joint Venture
Type of license: Bingo Equipment Provider Raffle Equipment Provider Casino Equipment Provider
Instant Raffle Equipment Distributor/Manufacturer Armchair Race Equipment Provider
Business name: _ ___________________________________________________________________________
Contact person: _ ___________________________________________________________________________
Address: _________________________________________________________________________________
City
State ZIP code County
Street address
Mailing address (if different): ________________________________________________________________
City
State ZIP code County
Street address
Business address (if different): _ _______________________________________________________________
City
State ZIP code County
Street address
Business telephone number:__________________________ Home telephone number: ___________________
(Include area code)
(Include area code)
New Jersey sales tax number:__________________________ Federal ID number: ______________________
Return this application and the appropriate fee to:
Legalized Games of Chance Control Commission
P.O. Box 46000
Newark, N.J. 07101
(Revised 4/6/16)

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