Form Pt-6 - Pull Tabs Application For License Form - Illinois Department Of Revenue Page 2
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1
2Step 3 continued:
Tell us about people in your organization
4
List the following information about the organization’s president, secretary, and person in charge of selling pull tabs.
_______________________________
___ ___ ___ - ___ ___ - ___ ___ ___ ___
____/____/____
_____________
President’s name (include middle initial)
Social Security number
Date of birth
Race*
_______________________________
__________________________________________________
(_____)_______________
Street address
City
State
ZIP
Daytime telephone number
_______________________________
___ ___ ___ - ___ ___ - ___ ___ ___ ___
____/____/____
_____________
Secretary’s name (include middle initial)
Social Security number
Date of birth
Race*
_______________________________
__________________________________________________
(_____)_______________
Street address
City
State
ZIP
Daytime telephone number
_______________________________
___ ___ ___ - ___ ___ - ___ ___ ___ ___
____/____/____
_____________
Person in charge’s name (include middle initial)
Social Security number
Date of birth
Race*
_______________________________
__________________________________________________
(_____)_______________
Street address
City
State
ZIP
Daytime telephone number
* A — Asian or Pacific Islander; B — Black; I — American Indian or Alaskan Native; W — White; or O — Other
Step 4: Tell us about your pull tabs sales
1
4
In what municipality or county will you make the most money from
Make your check for $50 payable to “Illinois Department of
pull tabs sales?
Revenue.” Go to Step 5.
_____________________________________________________
5
Where will pull tabs be sold?
2
Will you be selling pull tabs on more than two occasions this year?
Number and street _____________________________________
Each occasion can be no longer than five consecutive days.
City, state, ZIP _________________________________________
_____
yes
_____ no
6
If “yes,” go to Item 5. You are applying for a pull tabs license.
Do you rent a premises for the purpose of conducting bingo?
If “no,” go to Item 3. You are applying for a limited pull tabs
_____ yes
_____ no
license.
If “yes,” pull tabs may be sold on such premises only during your
bingo session. Where is this premises located?
3
What are the two time periods pull tabs will be sold and where will
Number and street _____________________________________
they be sold? Note: If the last date is not known at this time, you
City, state, ZIP _________________________________________
must let us know the exact date 30 days before the event.
7
Make your check for $500 payable to “Illinois Department of
First time period:
_____/_____/_____ to _____/_____/_____
Revenue.” Go to Step 5.
Month
Day
Year
Month
Day
Year
Number and street _____________________________________
City, state, ZIP _________________________________________
Second time period: _____/_____/_____ to _____/_____/_____
Month
Day
Year
Month
Day
Year
Number and street _____________________________________
City, state, ZIP _________________________________________
Step 5: Sign below
Under penalties of perjury, I state that I have read the pull tabs rule
If you are applying for a
book. I also state that I have examined this application and, to the
pull tabs license, make your check for $500
best of my knowledge, it is true, correct, and complete.
limited pull tabs license, make your check for $50
payable to “Illinois Department of Revenue.”
President’s signature ______________________________________
Date
Mail your application and payment to:
Secretary’s signature ______________________________________
OFFICE OF BINGO AND CHARITABLE GAMES
Date
ILLINOIS DEPARTMENT OF REVENUE
Person in charge’s signature ________________________________
PO BOX 19480
Date
SPRINGFIELD IL 62794-9480
PT-6 Back (R-4/01)
If you have questions, call 217 524-4164.
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