Form Cg-3 - Special Bingo License Application - 1996 Page 3
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4Game and Prize Information
15. Will your organization be conducting a door prize drawing during the bingo event?
Yes
No
16. Will your organization be selling pull tabs, punchboards, and tip boards?
Yes
No
17. You may request special permission to increase certain prize limitations. See Charity Gaming Publication 2 for more information.
NOTE: This license does not authorize a raffle drawing to be held at this event.
Manufacturer and Distributor Information
18. List the manufacturer(s) and/or distributor(s) from whom you currently intend to purchase bingo supplies, pull tabs, punchboards, or tip
boards. Attach additional sheets if necessary.
Name
Address
City
State
Zip Code
Items
Financial Information
19. Where will the charity gaming financial records be maintained?
Address
City
State
Zip Code
20. Name, address, and telephone number of the person maintaining these records.
Name
Address
City
State
Zip Code
Daytime Telephone Number
(
)
21.
Note: All net proceeds from an allowable event and related activities may only be used for the lawful purposes of the
qualified organization. I.C. 4-32-9-16.
22. Organization's Banking Information (Attach additional sheets if necessary.)
Name of Bank
Street Address
City
State
Zip Code
Name of Account
Account Number
Type of Account (checking, savings, CD)
Name of Account
Account Number
Type of Account (checking, savings, CD)
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