Instructions For Form Wv/bgo-1 (Application For Charitable Bingo License) (Page 4 of 5) in pdf

Instructions For Form Wv/bgo-1 (Application For Charitable Bingo License) Page 4

present at all times bingo is conducted. For a limited occasion license, only two

names are required.

SECTION 12 – NAME OF HIGHEST ELECTED OFFICER AND DESIGNEE

List the names, titles, home addresses and home telephone numbers of

the highest elected officer of the licensee and his or her officially appointed

designee. One of these persons must be present at all times bingo is conducted.

SECTION 13

Indicate by circling the appropriate answer whether the organization has

ever been denied a bingo license, or whether any previous license issued to the

organization has been revoked or suspended. If the answer is “yes,” attach an

explanation on a separate sheet.

Indicate whether any member of the organization who will participate in

any way in the conduct of bingo has been convicted of a felony, or a

misdemeanor for a gambling offense within the previous ten years. If the answer

is “yes,” attach an explanation on a separate sheet.

SECTION 14 – DISPOSITION OF PROCEEDS

Indicate the organization or organizations to which proceeds will be

donated, using a separate sheet if necessary.

Indicate the intended charitable or public service purposes for which the

bingo proceeds will be expended.

SECTION 15 – AGREEMENT

By signing the application form, the authorized representative of the

organization is affirming that the persons in charge of the organization’s bingo

operations and the officers of the applicant organization understand:

(1) That it is a violation of the law to allow any unauthorized persons to conduct

any part of the bingo games or concessions;

(2) That the organization is required to file the reports and keep the records as

provided by the law; and

(3) That it is a crime to violate the provisions of the charitable bingo laws, and, in

addition, that a violation may result in suspension or revocation of the

organization’s license and denial of future licenses.

The signature on the application form by the authorized representative of

the organization is that person’s certification that the information contained in the

application is true to the best of his or her knowledge.

To avoid delays, make sure your application is complete, including your

check for the appropriate fee, your IRS exemption letter (not required for

renewals) and all other supporting documents, copies of all leases or rental

Instructions For Form Wv/bgo-1 (Application For Charitable Bingo License) Page 4