Form Bi-178 - Renewal Application For Registration Of Bingo Distributor
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1
2RENEWAL APPLICATION FOR REGISTRATION
FOR OFFICE USE ONLY
OF BINGO DISTRIBUTOR
$500
FEE
KANSAS DEPARTMENT OF REVENUE
Statutory Registration Fee
Charitable Gaming
Docking State Office Building
DISTRIBUTOR NO.
915 SW Harrison Street
Topeka, Kansas 66612-1588
Phone: 785-368-8222 Facsimile: 785-296-4993
APPR.
ISSUED
Website:
o
o
Renewal Application
Discontinuation of Business
Date Business Ceased:________________________
:
:
1. Distributor’s Name and Mailing Address for Notices and Forms
2. Actual business location address
Name
Street, Route or P.O. Box No.
Street, Route or P.O. Box No.
City
State
ZIP
City
State
ZIP
3. Distributor’s Office or Business Phone Number (include area code): ___________________________________________________
4. Distributor’s Federal Employer Identification Number (FEIN):_________________________________________________________
5. List names and addresses of all offices, manufacturing and storage locations where your bingo records of sales to Kansas licensees
are kept and locations which will be involved in distributing disposable paper bingo cards or instant bingo tickets in Kansas. Use a
separate sheet if necessary:
Name
Complete Address
6. Full name, mailing address, and telephone number of person who will maintain records of sales of disposable paper cards and instant
bingo tickets in Kansas:
Name _____________________________________________________________
Phone Number_______________________
Complete Address__________________________________________________________________________________________
7. If owner(s) or corporate officers are not residents of Kansas, list name and address of the person within the state of Kansas authorized
to receive service of legal process:
Name _____________________________________________________________
Phone Number_______________________
Complete Address__________________________________________________________________________________________
8. Ownership Information - List the name, address, social security number, complete date of birth, home telephone number and title of all
owners, partners, corporate officers or directors. Enclose a separate sheet if necessary:
a) Name _
____________________________________ SSN ________________________
DOB________________________
Complete Home Address _
_________________________________________________________________________________
Home Phone Number
_________________________
Ownership Title
______________________________________________
b) Name
_____________________________________ SSN ________________________
DOB_
_______________________
Complete Home Address
__________________________________________________________________________________
Home Phone Number _________________________ Ownership Title ______________________________________________
c) Name ______________________________________ SSN ________________________
DOB________________________
Complete Home Address __________________________________________________________________________________
Home Phone Number _________________________ Ownership Title ______________________________________________
d) Name _____________________________________ SSN ________________________
DOB________________________
Complete Home Address __________________________________________________________________________________
Home Phone Number _________________________ Ownership Title ______________________________________________
BI-178
(Rev. 2-16)
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