Eligible Organization Games Of Chance Application - Pennsylvania Department Of Revenue Page 3
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4SCHEDULE SHEET
FOR ELIGIBLE ORGANIZATION GAMES OF CHANCE LICENSING
Please Print or Type All Information.
SCHEDULE A – Check which type(s) of games of chance the organization will conduct:
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Daily/Weekly Drawings
Pull-tab games
Punchboards
Raffles
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Race Night Games
Pools
50/50 Drawings
SCHEDULE B – List the following data for all officers, directors, owners and partners. If incorporated, list all officers and shareholders
controlling 10 percent or more of outstanding stock. If organized as a partnership, list data for all partners. For all other
entities, list data of any other financially responsible person.
Full Name
Date of Birth
Title or Relationship
Social Security Number (Optional)
Email Address
Telephone Number
Complete Mailing Address
Full Name
Date of Birth
Title or Relationship
Social Security Number (Optional)
Email Address
Telephone Number
Complete Mailing Address
SCHEDULE C – List all persons who will be responsible for operation of games of chance, including employees, bar personnel and
organizational members or auxiliary members who will obtain and coordinate use of games of chance.
Full Name
Date of Birth
Title or Relationship
Social Security Number (Optional)
Complete Mailing Address
Telephone Number
Full Name
Date of Birth
Title or Relationship
Social Security Number (Optional)
Complete Mailing Address
Telephone Number
Full Name
Date of Birth
Title or Relationship
Social Security Number (Optional)
Complete Mailing Address
Telephone Number
SCHEDULE D - List distributors with which the organization anticipates doing business:
Name of Distributor and distributor license number
Complete Mailing Address
Telephone Number
SCHEDULE E – List all auxiliary groups of the applicant conducting games of chance under the applicant’s license:
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THIS FORM MAY BE REPRODUCED
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