Form Rb-2 - Application For Bingo Supplier'S License - Illinois Department Of Revenue
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3Illinois Department of Revenue
RB-2
Application for
License no. ____________________
Bingo Supplier’s License
License issued _________________
Do not write above this line.
Step 1: Identify your business
List all of the following numbers that your business has
Business name __________________________________________
been assigned.
Physical address _________________________________________
IBT no. ____ ____ ____ ____ - ____ ____ ____ ____
Number and street
FEIN
____ ____ - ____ ____ ____ ____ ____ ____ ____
_________________________________________________________
Bingo license no.
B -
_________________
City
State
ZIP
Bingo provider’s license no.
BP - _________________
( _____ ) ______________________
________________________
Charitable game license no.
CG - _________________
County
Telephone number
Charitable game provider’s license no.
CP - _________________
Mailing address __________________________________________
Charitable game supplier’s license no.
CS - _________________
Number and street or post office box
Pull tab license no.
P -
_________________
_______________________________________________________
Pull tab supplier’s license no.
PS - _________________
City
State
ZIP
Pull tab manufacturer’s license no.
PM - _________________
Step 2: Tell us about your business
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Check your type of business ownership.
Are you a foreign corporation?
yes
no
Individual
Partnership
Corporation
If “yes,” when did you qualify to do business in Illinois?
Other (please specify)______________________________
Date __ __/__ __/__ __ __ __
Month
Day
Year
If you are a corporation, attach your articles of incorporation and
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bylaws. If this is a renewal application, attach these items only if
Are you doing business under an assumed name?
they have changed since your last application.
yes
no
If “yes” and you are an individual, a partnership, or an other entity,
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When and where was your business established?
write the county and number of your Assumed Name Certificate.
Date __ __/__ __/__ __ __ __
County_______________________
Number ______________
Month
Day
Year
City _________________________ State ________________
If “yes” and you are a corporation, attach a certified copy of your
Certificate of Registration.
Step 3: Identify your director, officers, partners, and stockholders
If your business is owned or operated by another entity, you must also identify the director, officers, partners, and stockholders
of that entity. Attach additional sheets if necessary. If you are a partnership or a corporation, you must report to us in writing
within 30 days any change in the number or identity of persons owning at least 10 percent of the shares in your business or an
entity that owns or operates your business.
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_______________________________
_____________________________
__ __ __ - __ __ -__ __ __ __
__ __/__ __/__ __ __ __
Name (include middle initial)
Title (if applicable)
Social Security number
Date of birth
_______________________________
____________________________________________________________
______________
Street address
City
State
ZIP
Race*
2
_______________________________
_____________________________
__ __ __ - __ __ -__ __ __ __
__ __/__ __/__ __ __ __
Name (include middle initial)
Title (if applicable)
Social Security number
Date of birth
_______________________________
____________________________________________________________
______________
Street address
City
State
ZIP
Race*
3
_______________________________
_____________________________
__ __ __ - __ __ -__ __ __ __
__ __/__ __/__ __ __ __
Name (include middle initial)
Title (if applicable)
Social Security number
Date of birth
_______________________________
____________________________________________________________
______________
Street address
City
State
ZIP
Race*
4
_______________________________
_____________________________
__ __ __ - __ __ -__ __ __ __
__ __/__ __/__ __ __ __
Name (include middle initial)
Title (if applicable)
Social Security number
Date of birth
_______________________________
____________________________________________________________
______________
Street address
City
State
ZIP
Race*
* A — Asian or Pacific Islander; B — Black; I — American Indian or Alaskan Native; W — White; or O — Other
RB-2 (R-3/96)
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