Form Et 388 - Application For Non-Profit Organizations To Conduct Bingo Games And Raffles
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3STATE OF ARKANSAS
DEPARTMENT OF FINANCE AND ADMINISTRATION
APPLICATION FOR NON-PROFIT ORGANIZATIONS
TO CONDUCT BINGO GAMES AND RAFFLES
Class Code 5101
Type of License:
Original Renewal*
(check the appropriate box)
A. $100.00 License to operate games of “Bingo” & “Raffle”…………………………………………...…………………
B. $25.00 Temporary License to conduct one (1) “Bingo” session...………………………………………........................
C. $25.00 Class I Temporary License to conduct one (1) “Raffle”………………………………………….......................
D. $10.00 Class II Temporary License to conduct one (1) “Raffle” [Product donated and less than $5,000 value]………
*If renewal application, list current permit #: ________________
Name of Organization: ______________________________________________________
FEIN_____-______________________
Contact person: ____________________________________________________________________________________________________
Phone number: (
) ________ - ______________
Best contact days/times:_____________________________________________
Ownership type:
Non-profit
Government
Fiduciary/Trust (non-revocable)
Corporation
Single-member LLC
Fiduciary/Trust (revocable)
LLC
Partnership
Sole Proprietor
S-corporation
1) Mail-to address (address to which forms will be mailed)
Address:________________________________________________________________________________________________________
(
Street address / P.O. Box)
(City)
(State)
(Zip)
2) Physical address (address of premises where Bingo or Raffle is to be held)
Address:______________________________________________________________________________________________________
(
Street address)
(City)
(County)
(State)
(Zip)
Check one:
Premises are owned by the Organization
Premises are leased/rented by the Organization – (Attach copy of lease agreement)
Official Use Only
Official Use Only
Official Use Only:
Permit No. _________________
Check number: ____________________
Status: Approved / Denied
Permit duration
Check date:
____________________
Reviewer:____________________________
From: ______/_______/______
Check amt:
$____________________
Date: _______/________/________
To: ______/_______/______
ET 388 - Bingo/Raffle - License Application and Certification (Revised 3/10)
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Parent category: Legal