Form Bi-60 - Initial Application For Bingo License Form - Kansas Department Of Revenue
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1
2INITIAL APPLICATION FOR BINGO LICENSE
FOR OFFICE USE ONLY
KANSAS DEPARTMENT OF REVENUE
$25
FEE
Charitable Gaming
Statutory Registration Fee
Docking State Office Building
915 SW Harrison Street
BINGO LICENSE NO.
Topeka, Kansas 66612-1588
Phone: 785-368-8222 Facsimile: 785-296-4993
Website:
APPR.
ISSUED
See the Kansas Bingo Handbook, Section I - Licensed Organizations - Pages 1 and 2 for information
about the application process. Mail the completed application and $25 fee to the address above.
:
:
1. Organization’s Name and Mailing Address for Notices and Forms
2. Exact address where bingo games will be conducted
Name
Street, Route or P.O. Box No.
Street, Route or P.O. Box No.
City
State
ZIP
City
State
ZIP
3. Organization’s Federal Employer Identification Number (FEIN): _______________________________________________________
4. Organization’s office or business phone number (include area code): _________________________________________________
5. Member of your organization that we may contact regarding conduct of bingo games and review of records:
______________________________________________________________________________________________
Name
Title
Daytime Phone Number
______________________________________________________________________________________________
Email Address
FAX Number
o
o
6. Will bingo games be conducted on leased or rented premises?
No
Yes If yes, list lessor’s bingo premises name and registration
number: ________ Enclose a copy of your lease agreement.
7. Which days of the week or month will bingo games be conducted?
Exact time of day when you will start conducting bingo games: Mini games:
_________
Regular games:
_________
List any months of the year when you will NOT be conducting bingo games:
____________________________________________
8. Is your organization registered to collect and remit Kansas sales tax at the location where bingo games will be conducted?
o
o
No
Yes
If yes, enter your sales tax registration number: ____________________________
o
o
o
o
o
9. Type of non-profit organization—check one:
Religious
Educational
Charitable
Veterans
Fraternal
10. Type of organizational entity and affiliation (check as many as apply):
o
Local organization is a non-profit corporation. Indicate date and state of incorporation: ________________________________
o
Local organization is an unincorporated, independent association or club.
o
Local organization is chartered by or affiliated with a state, regional or national organization. Name and address of chartering or
parent organization: ___________________________________________________________________________________
11. Number of months or years that your local organization has been in existence in Kansas:
_______
(This applies to your specific
local organization, not to any national or state organization with which you may be affiliated.)
o
o
12. Is membership in your organization denied to any person for reasons of race, color or physical handicap?
No
Yes
13. Attach a list of all current members of your organization, including their full legal name, complete address and date they became a
o
o
member. Are your members required to pay dues?
No
Yes
BI-60
(Rev. 2-16)
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