Form Cg-6 - Door Prize License Application - Indiana Department Of Revenue
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4For Official Use Only
Form
License Fee Paid _____________
CG-6
Indiana Department of Revenue
Date Received ______________
Rev. 6-96
Reviewed By ______________
SF-45386
Door Prize License Application
Date Entered _______________
You must file this application at least six (6) weeks before your scheduled door prize event.
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 door prize 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 door prize 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. 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, etc.) being leased or donated to you for this event?
Yes
No
If you
answered yes, list below 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
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Parent category: Financial