Form Wv/bgo-1 - Application For Regular Annual, Limited Or State Fair Bingo License (Page 2 of 2) in pdf

5. NAMES OF OFFICERS OF ORGANIZATION

LIST NAMES, HOME ADDRESSES AND HOME TELEPHONE NUMBERS OF ALL OFFICERS AND MEMBERS OF THE BOARD OF DIRECTORS, GOVERNORS

OR TRUSTEES, IF ANY, IN THE ORGANIZATION. ALL OFFICERS MUST BE OVER 18. (ATTACH ADDITIONAL SHEET IF NECESSARY)

NAME AND TITLE

HOME ADDRESS

HOME TELEPHONE NUMBER

6. PERSONS IN CHARGE OF BINGO

LIST NAMES, HOME ADDRESSES AND TELEPHONE NUMBERS OF PERSONS IN CHARGE OF BINGO OCCASIONS. THESE PERSONS MUST BE BONA

FIDE MEMBERS OF YOUR ORGANIZATION AND RESIDENTS OF THE STATE OF WEST VIRGINIA. ANNUAL LICENSES REQUIRE 3 NAMES. LIMITED

LICENSES REQUIRE AT LEAST 2 NAMES. ONE OF THESE PERSONS MUST BE PRESENT AT ALL BINGO OCCASIONS. ALL PERSONS IN CHARGE

OF BINGO MUST BE OVER 18.

NAME AND TITLE

HOME ADRESS

HOME TELEPHONE NUMBER

7. NAME OF HIGHEST ELECTED OFFICER AND APPOINTED DESIGNEE

LIST NAMES, HOME ADDRESSES AND HOME TELEPHONE NUMBERS OF THE HIGHEST ELECTED OFFICER AND HIS APPOINTED DESIGNEE OF

ORGANIZATION. ONE OF THESE PERSONS MUST BE PRESENT AT ALL OCCASIONS. ALL PERSONS MUST BE OVER 18.

NAME AND TITLE

HOME ADDRESS

HOME TELEPHONE NUMBER

HIGHEST ELECTED OFFICER

APPOINTED DESIGNEE

8. LOCATION OF BINGO OCCASIONS

Address, City, Zip Code & County

Do you own the premises? YES

Do you rent or lease the premises? YES

List name of owner______________________________________________

PLEASE NOTE: YOU MUST ATTACH A COPY OF CURRENT RENTAL OR LEASE AGREEMENT WITH THE APPLICATION.

9. YOU MUST ANSWER THE FOLLOWING QUESTIONS:

Has your Bingo License Application ever been refused, denied, revoked, or suspended?

YES

Has any person in your Organization who will participate in any manner in the conduct of Bingo Games or related concessions ever been

convicted of a Felony, or Misdemeanor for a gambling offense within the past 10 years?

YES

If you answer yes to any of these questions, attach a separate sheet explaining.

10. DISPOSITION OF PROCEEDS

Recipient of Proceeds:

Does this recipient have an Internal Revenue Service Exemption Status Letter?

YES

Intended use of Proceeds:

PLEASE NOTE: YOU MUST LIST THE NAMES OF ALL ORGANIZATIONS YOU INTEND TO DONATE PROCEEDS TO. ATTACH SEPARATE SHEET IF

NECESSARY.

11. AGREEMENT

I fully understand that it is a violation of Chapter 47, Article 20 to allow anyone other than authorized persons to conduct any part of the Bingo Games

or Concessions; That I am required to file reports and keep records as provided by Article 20; That is it a crime to violate any provisions of Article 20;

That a violation may result in suspension and/or revocation of the license and possible denial of subsequent license applications.I,

________________________________________, AS AN AUTHORIZED REPRESENTATIVE OF___________________________________________,

CERTIFY OR AFFIRM THAT THE STATEMENTS AND ITEMS ENTERED HEREIN AND ATTACHED HERETO ARE TRUE AND CORRECT TO THE BEST OF MY

KNOWLEDGE.________________________

________________________________________

______________________

Date

Signature

Title