Form Rb-2 - Application For Bingo Supplier'S License - Illinois Department Of Revenue Page 2
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1
2
3Step 4: Have each person listed in Step 3 complete the following information
Make a copy of this step for each individual to complete. Attach all completed copies to your application. Attach additional
sheets if necessary.
1
15
Name _______________________________________________
Write the name and address of each business in which you have
First
Middle
Last
a financial interest or an active role.
2
a
Previous or maiden name (if applicable)
Business name _____________________________________
____________________________________________________
Street address _____________________________________
First
Middle
Last
City, state, ZIP _____________________________________
3
Home address ________________________________________
Number and street
b
Business name _____________________________________
____________________________________________________
Street address _____________________________________
City
State
ZIP
City, state, ZIP _____________________________________
4
How long have you resided at this address? _________________
16
Write your employment history for the past 10 years. List your
5a
Home phone (______)__________________________________
most current employer first. Include periods of unemployment or
b
Work phone (______)__________________________________
education.
a
Employer name _____________________________________
6a
Date of birth __ __/__ __/__ __ __ __
Street address _____________________________________
b
Place of birth _________________________________________
City, state, ZIP _____________________________________
City
State
Position held
_____________________________________
7
Social Security number ___ ___ ___ - ___ ___ - ___ ___ ___ ___
Dates of employment ________________________________
Type of business ___________________________________
8a
Drivers license number _________________________________
b
b
State of issue _________________________________________
Employer name _____________________________________
c
Date of issue __ __/__ __/__ __ __ __
Street address _____________________________________
Month
Day
Year
City, state, ZIP _____________________________________
9
Spouse’s name _______________________________________
Position held
_____________________________________
First
Middle
Last
Dates of employment ________________________________
10
Spouse’s previous or maiden name (if applicable)
Type of business ___________________________________
____________________________________________________
First
Middle
Last
17
List your places of residence during the past 10 years, excluding
11
Are you a U.S. citizen?
yes
no
the home address you provided in Item 3 above.
a
If “no,” write your registration number. _____________________
Street address _____________________________________
City, state, ZIP _____________________________________
12
What position do you hold with this business?
Dates of residence __________________________________
sole proprietor
stockholder
b
director
manager
Street address _____________________________________
officer
other __________________
City, state, ZIP _____________________________________
partner
Dates of residence __________________________________
13
18
Describe your duties with this business. ____________________
Have you ever been convicted of a felony or a misdemeanor?
____________________________________________________
yes
no
____________________________________________________
If “yes,” explain. _______________________________________
____________________________________________________
14
List all of the following numbers assigned to you or a business
19
or organization in which you have a financial interest or an
Do you belong to any organizations not listed in Item 14 that
active role.
conduct lawful gambling?
yes
no
IBT no. ____ ____ ____ ____ - ____ ____ ____ ____
If “yes,” write the following information for each organization.
a
FEIN
____ ____ - ____ ____ ____ ____ ____ ____ ____
Organization name __________________________________
Bingo license no.
B - _______________
Street address _____________________________________
Bingo supplier’s license no.
BS - _______________
City, state, ZIP _____________________________________
Bingo provider’s license no.
BP - _______________
License no. _______________________________________
Charitable game license no.
CG - _______________
b
Charitable game provider’s license no.
CP - _______________
Organization name __________________________________
Charitable game supplier’s license no.
CS - _______________
Street address _____________________________________
Pull tab license no.
P -
_______________
City, state, ZIP _____________________________________
Pull tab supplier’s license no.
PS - _______________
License no. _______________________________________
Pull tab manufacturer’s license no.
PM - _______________
20
Sign your name ________________________ Date__________
RB-2 (R-3/96)
Page 2 of 3
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