Form Wv/bgo-1 - Application For Regular Annual, Limited Or State Fair Bingo License
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1
2WV/BGO-1
West Virginia State Tax Department
Rev. 09/05
Charitable Bingo/Raffle Unit
PO Box 1143
Charleston WV 25324-1143
304-558-8510
APPLICATION FOR REGULAR ANNUAL, LIMITED OR STATE FAIR BINGO LICENSE
TAX IDENTIFICATION NUMBER
TELEPHONE:
B
NAME:
ADDRESS:
Apply for the license which best serves your needs. You may hold only one valid regular annual license. While it is valid, you may apply and receive
one limited license. All bingo licenses are subject to the Rules & Regulations of the State Tax Commissioner and must be conspicuously displayed at
the location where the Bingo Occasion is held. All Bingo Occasions shall be open to the general public. PLEASE NOTE: THIS APPLICATION MUST
BE FILED AT LEAST 60 DAYS PRIOR TO THE DATE SCHEDULED FOR THE FIRST BINGO OCCASION
I
IS THIS A RENEWAL APPLICATION?
YES
NO
(Circle One)
1. 501(C) STATUS
Have you been granted 501(c) tax exempt status from the Internal Revenue Service?
YES
NO (Circle One)
TYPE OF EXEMPTION LETTER YOUR ORGANIZATION POSSESSES
501(C)3
501(C)4
501(C)8
501(C)10
501(C)19
501(D) (Circle One)
PLEASE NOTE: YOU MUST ATTACH A COPY OF YOUR CURRENT 501(C) EXEMPTION LETTER TO THIS APPLICATION.
2. TYPE OF LICENSE
_____ANNUAL LICENSE $500.00
_____ANNUAL SENIOR $50.00
_____ANNUAL $200.00 ONLY APPLICABLE FOR ORGANIZATIONS WHOSE ANNUAL GROSS PROCEEDS ARE LESS THAN $20,000 PER YEAR
Please indicate the day(s) of the week your Bingo occasion(s) will be conducted and give the actual playing time:
N
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
(Circle Days Played)
Date of your first Bingo Occasion:
Hour(s) Bingo will be held:
_____LIMITED LICENSE $100.00
Entitles an organization to hold a Bingo occasion once every 24 hours for a period not to exceed 2 weeks. An occasion may not exceed 12 hours
duration. No more than three (3) Limited Licenses may be granted in one year. List the actual dates and playing times Bingo will be conducted.
HOLDERS OF ANNUAL LICENSES MAY BE GRANTED NO MORE THAN ONE LIMITED LICENSE PER YEAR.
Date of Bingo
Date of Bingo:
Time of Bingo(s):
G
_____STATE FAIR LICENSE $500.00
STATE FAIR: AN APPLICATION FOR A STATE FAIR LICENSE MUST INCLUDE A COPY OF ANY LEASE AGREEMENT ENTERED INTO BETWEEN THE STATE
FAIR BOARD AND THE PERSONS WHO ARE TO CONDUCT THE BINGO OCCASIONS.
Has the operator of the Bingo occasions conducted Bingo at the State Fair for at least 2 years prior to the filing of this application?
YES
NO
(Circle One)
Date of your first Bingo Occasion:
Hour(s) Bingo will be held:
3. PROOF OF EXISTENCE (NOT REQUIRED FOR RENEWAL APPLICANTS)
HAS YOUR ORGANIZATION BEEN IN EXISTENCE IN WEST VIRGINIA TWO YEARS PRIOR TO FILING THIS APPLICATION:
O
YES
NO
(Circle One)
IF YES, YOU MUST ATTACH DOCUMENTARY PROOF, THIS DOCUMENT IS NECESSARY TO QUALIFY FOR A BINGO LICENSE.
4. CONCESSIONS
WILL A CONCESSION BE OPERATED?
YES
NO
(Circle One)
WILL THE LICENSEE OPERATE THE CONCESSION?
YES
NO
(Circle One)
PLEASE NOTE: IF THE CONCESSIONS ARE TO BE OPERATED BY SOMEONE OTHER THAN THE LICENSEE, A COPY OF ANY AGREEMENT OR AN
EXPLANATION OF ANY ORAL AGREEMENT PROVIDING OF ANY TYPE OF COMPENSATION OF THE CONCESSION MUST BE ATTACHED.
FOR OFFICE USE ONLY
Date Approved:
Approved By:
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