Form Cg-Ael - Application For Exemption Letter For Non-Licensed Event July 2005 Page 2
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1
2Operator Information
You must complete this information for each Operator listed on the front of this form.
1. Operator Name
2. Operator Name
Home Address
Home Address
City, State, Zip Code
City, State, Zip Code
Telephone #
Telephone #
(
)
(
)
Date of Birth
Date of Birth
Social Security #
Social Security #
Years of Membership
Years of Membership
3. Operator Name
4. Operator Name
Home Address
Home Address
City, State, Zip Code
City, State, Zip Code
Telephone #
Telephone #
(
)
(
)
Date of Birth
Date of Birth
Social Security #
Social Security #
Years of Membership
Years of Membership
Note: If your organization is using purchased, leased or donated bingo equipment or punchboards, pull
tabs, or tip boards, they must be purchased from a licensed distributor.
Distributor Name
Address
License Number
Items Purchased
For a list of licensed distributors, contact the Department at (317) 232-4646.
Send completed form to:
Indiana Department of Revenue
Charity Gaming Section
100 N. Senate Ave., Room N203
Indianapolis, IN 46204
CG-AEL (2)
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