For Official Use Only
Form
License Fee Paid _____________
CG-3
Indiana Department of Revenue
Date Received ______________
Rev. 6-96
Reviewed By ______________
SF-45382
Special Bingo License Application
Date Entered _______________
You must file this application at least six (6) weeks before your scheduled bingo game.
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 what date and during what hours will your special bingo event be conducted? (A.M. establishes the midnight hour, P.M. establishes the
noon hour.) (This session can run for no more than 8 consecutive hours.)
Date _________________
Hours ___________ ___M to ____________ ___M
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 statement
from the donor that the facility is being offered rent free. NOTE: Check this box
if the rented facility is being used for an annual
convention or other yearly meeting of your organization's (or your affiliate's) membership.
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
$
$
$
Turn the page
1