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 Page 2

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B. Corporate Identification
Full name of the corporation and any trade names: ________________________________________________
Date of Incorporation: ________________________ State of Incorporation: _ __________________________
Attach a true (reflecting that it has been filed) copy of the certificate/articles of incorporation and by-laws and
any amendments to either.
Provide the names and addresses of all officers, directors, and holders of 10% or more of stock in the applicant
corporation. If any officer, director or stockholder who holds 10% or more of the stock in the applicant corporation is
himself/herself/itself registered as a corporation, provide the name and address of all officers, directors or
holders of 10% or more of the stock in that corporation.
Name: ____________________________________________ Title: _ _________________________________
Number of shares held: ___________________________ Percentage (%) of stock held: __________________
Residence address: _________________________________________________________________________
City
State ZIP code
County
Street address
Name: ____________________________________________ Title: _ _________________________________
Number of shares held: ___________________________ Percentage (%) of stock held: __________________
Residence address: _________________________________________________________________________
City
State ZIP code
County
Street address
Name: ____________________________________________ Title: _ _________________________________
Number of shares held: ___________________________ Percentage (%) of stock held: __________________
Residence address: _________________________________________________________________________
City
State ZIP code
County
Street address
(Section D must be completed by each person named above.)
C. Identification Statement for Partnerships, Associations and Joint Ventures
Attach copies of the documents creating the entity and any supplements that reflect such changes.
Type of entity: ____________________________ Is the entity registered? Yes No
If "Yes," where? _ ___________________________________________________________________
Provide the names and addresses of all real parties in interest. Attach a statement disclosing the complete
and accurate nature and extent of each party's interest.
Name: ___________________________________________________________________________________
Address: _________________________________________________________________________________
City
State ZIP code County
Street address
Interest held: ______________________________________
Is the entity indebted to any person named above in any fashion other than what has been disclosed herein?
Yes No
If "Yes," attach a statement to this application providing the complete and accurate details of the indebtedness.
For all applicants, if additional space is needed, attach a notarized addendum to this application.

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