Form Bsl-Cg-2236 - Qualification Information - Michigan Gaming Control Board
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3QUALIFICATION INFORMATION
If this form does not
The organization must complete this form and submit with the qualification documents.
accompany the qualification documents, documents will be returned to contact person. This will
delay processing. Any misrepresentation is grounds for denial.
Please check the appropriate box(es) for the license you wish to obtain.
Application(s) and fee(s) enclosed?
Millionaire Party
Bingo
Raffle
Charity Game Ticket
Yes
No
1. Name of Organization
2. Doing Business As (DBA) (if applicable)
3. US Federal Employer Identifi cation Number
4. Organization Physical Address
City
State
Zip
County
5. Organization Mailing Address
Same as Physical Address
City
State
Zip
County
6. Telephone Number
7. Fax Number
8. Date Organization Established
9. Briefly describe the purpose of the organization
10. Name of Authorized Contact Person
11. Authorized contact person’s position or role with organzation
12. Mailing Address
City
State
Zip
County
13. Email Address
14. Telephone Number
15. Fax Number
The undersigned hereby certifies that the representations, information and data, presented are true, accurate and complete
to the best of the undersigned’s knowledge. The undersigned understands that failure to answer truthfully, completely and
accurately could preclude the organization from receiving an approval to obtain a gaming license.
Authorized Contact Signature
Date
Print Name and Title
PLEASE READ CAREFULLY
If you are qualifying for a millionaire party license, mail this completed form and the required qualification
documentation to Michigan Gaming Control Board, PO Box 30786, Lansing, MI 48909.
If you are qualifying for a raffle, bingo, or charity game ticket license, mail this completed form and the
required qualification documentation to Charitable Gaming Division, PO Box 30023, Lansing, MI 48909.
If you are qualifying for a millionaire party AND raffle, bingo, or charity game license, you must submit
copies of this form and all qualification documents to BOTH agencies.
*310*
Authority: Act 382 of the Public Acts of 1972, as amended.
BSL-CG-2236(8/12)
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