Form Cg-2 - Annual Bingo License Application - 1996
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4For Official Use Only
Form
Indiana Department of Revenue
License Fee Paid _____________
CG-2
Annual Bingo License Application
Date Received ______________
Rev. 6-96
Reviewed By ______________
SF-45381
For First Time Applicants
Date Entered _______________
Processing of this application can take up to 90 days.
1. Name of organization (please type or print)
STOP! Get Charity
Gaming Publication 2
2. Previous name of organization (if name changed)
for more information.
3. Street address of principal office (as it appears on the Charity Gaming Qualification Application, Form CG-1)
City
State
Zip Code
County
Daytime telephone number
(
)
4. On which days of the week and during what hours will your bingo event be conducted? (A.M. establishes the midnight hour,
P.M. establishes the noon hour.) (Time is limited to no more than 8 consecutive hours per session.)
Day __________ Hours _______ __M to _______ __M
Day __________ Hours _______ __M to _______ __M
Day __________ Hours _______ __M to _______ __M
Check this box if you wish to sell pull tabs, punchboards and tip
boards only, and not play bingo. (Also complete lines 6 through 26.)
5. Street address of the facility where the bingo event will be conducted and the DBA name (Doing business as) if applicable.
City
State
Zip Code
County
Daytime telephone number
(
)
Attach additional sheets if necessary
Leasing Information
to supply all information for each line.
6. Does your organization own _____, lease (rent) _____, or use a donated _____ facility where the licensed event will be conducted? (Check
one.) If leased (rented), enter name and address of lessor and attach a copy of your signed lease agreement. If donated, attach a notarized
statement from the donor that the facility is being offered rent free.
Name of lessor (full legal name)
Address
City
State
Zip Code
County
Daytime telephone number
(
)
7. Is any tangible personal property (i.e. tables, chairs, bingo blowers, etc.) being leased or donated to you for this event?
Yes
No
If you answered yes, list the name and address of the lessor or donor. Attach a signed copy of the lease agreement or donation statement
from the donor.
Name
Address
City
State
Zip Code
8. Does your organization own bingo equipment? Yes
No
If you answered yes, list the seller's name, date of purchase, purchase
price, and the type of equipment purchased.
Name of Seller
Date of Purchase
Purchase Price
Equipment Type
$
$
$
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