Form Bi-178 - Renewal Application For Registration Of Bingo Distributor Page 2

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9. Employee Information - List the name, address, social security number, complete date of birth, home telephone number and title
of each employee of the applicant, including salespeople operating as independent contractors or subcontractors of the applicant.
Enclose a separate sheet if necessary:
a) Name _____________________________________ SSN ________________________
DOB________________________
Complete Home Address __________________________________________________________________________________
Home Phone Number _________________________ Employment Title ____________________________________________
b) Name _____________________________________ SSN ________________________
DOB________________________
Complete Home Address __________________________________________________________________________________
Home Phone Number _________________________ Employment Title ____________________________________________
c) Name______________________________________ SSN ________________________
DOB________________________
Complete Home Address __________________________________________________________________________________
Home Phone Number _________________________ Employment Title ____________________________________________
d) Name _____________________________________ SSN ________________________
DOB________________________
Complete Home Address __________________________________________________________________________________
Home Phone Number _________________________ Employment Title ____________________________________________
10. Has any of the persons listed in items 8 and 9 been convicted of, pleaded guilty to, or pleaded nolo contendere (no contest) to, any
o
o
felony or illegal gambling violation in any state or the United States or any other country?
No
Yes If yes, list name of each
such person and particulars on a separate page and enclose with to this application.
Name ___________________________________________________________________________________________________
Particulars (list any charges/convictions, dates) __________________________________________________________________
Name ___________________________________________________________________________________________________
Particulars(list any charges/convictions, dates)___________________________________________________________________
Name ___________________________________________________________________________________________________
Particulars (list any charges/convictions, dates) __________________________________________________________________
Name ___________________________________________________________________________________________________
Particulars (list any charges/convictions, dates) __________________________________________________________________
Name ___________________________________________________________________________________________________
Particulars (list any charges/convictions, dates) __________________________________________________________________
Name ___________________________________________________________________________________________________
Particulars (list any charges/convictions, dates) __________________________________________________________________
Name ___________________________________________________________________________________________________
Particulars (list any charges/convictions, dates) __________________________________________________________________
VERIFICATION OF BINGO DISTRIBUTOR - MUST BE SIGNED AND NOTARIZED
STATE OF KANSAS
)
)
ss:
COUNTY OF________________________________ )
The undersigned, of lawful age, being first duly sworn, upon his or her oath, states:
That the undersigned has read and knows the contents of the above Initial Application for Bingo Card Distributors and that
the answers and information provided therein are true, correct and complete.
_____________________________________________________________
_______________________________________________________
Signature of Owner, Partner or Corporate Officer
Typed or Printed Name
_____________________________________________________________
Title
SUBSCRIBED AND SWORN TO before me this
day of
, 20
______________
_____________________________________
________
_______________________________________________________
Notary Public
My Appointment Expires
____________________________

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