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 4

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E. Statement of Applicant:
State of __________________________
}
ss.
County of ________________________
I swear/affirm that I have read N.J.S.A. 5:8-1 et seq. together with the regulations governing the conduct of
legalized games of chance, N.J.A.C. 13.47-.1.1 through 13:47-20.41, and fully understand that in receiving a
bingo/raffle equipment provider's license, instant raffle equipment distributor/manufacturer license, or a casino
night/armchair races equipment provider license from the Legalized Games of Chance Control Commission, I agree
to be governed by them.
I further swear/affirm that the information contained in this application and in any attachment is true, accurate
and complete.
If I am completing this application on behalf of a corporation or other business applicant, I further swear/affirm
that I am authorized to make this application on behalf of that applicant.
Sworn and Subscribed to before me
this _______ day of _______, 20___
Month Year
_________________________________________
______________________________
Signature and Title
Signature of Notary Public
____________________________
_________________________________________
Date commission expires
Printed Name and Title

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