Form Cg-3 - Special Bingo License Application - 1996 Page 2
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4Operator and Worker Information
9. Please list each bingo operator who will supervise, manage, and be responsible for the operation and conduct of the gaming event. Attach
additional sheets if necessary. Please type or print.
Daytime
No. of active
Date
Social Security
Telephone
years with
of Birth
Name
Home Address
Number
Number
group
(
)
(
)
(
)
(
)
(
)
10. Please list the name from Line 9 of the principal person in your organization who has overall responsibility for the operation and control of
this charity gaming event. Please type or print.
_________________________________________________
11. Are any of the operators listed on Line 9 also operators for any other organization's charitable gaming events? Yes
No
If you
answered yes, list each individuals name, name of organization, and the month(s) that they will operate other gaming events. Attach
additional sheets if necessary.
12. List all individuals (excluding operator information on Line 9) who will assist and work in the operation of the licensed event. Attach
additional sheets if necessary. Please type or print.
Daytime
Member of
Social Security
Date
Telephone
organization?
Number
of Birth
Name
Home Address
Number
Yes
No
(
)
(
)
(
)
(
)
(
)
13. Have any operators or workers listed above been convicted of a felony in any jurisdiction?
Yes
No
If you answered yes, list
each name and date of conviction.
Concession Information
14. a. Will concessions be offered during the licensed event? (Check one) Yes* ________
No ________
*If yes, complete the following information. If the concessionaire is required to have a retail merchant certificate, enter that number
in the box provided.
Name of organization offering the concessions
Concessionaire's Retail Merchant Certificate Number
b. Which of the following will your organization be receiving? (Check one.)
_____ All of the concession income
_____ A flat fee concession payment
_____ A percentage of the concession income
_____ Other (explain) ____________________________________________
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