Form 201 - R - Charitable Gaming Permit Application Renewal Applicants Only Page 3

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ORGANIZATION INFORMATION

16.

Has any officer, director, or game manager who participates in the

management or operation of any charitable gaming activity ever been (a)

convicted of a felony, (2) convicted of any misdemeanor involving fraud,

theft or financial crimes within the preceding five years of this application, or

(3) participated in the management, operation or conduct of any charitable

game which was found by the Office or a court of competent jurisdiction to

If Yes, please provide name,

have been operated in violation of state law, local ordinance, or Office

address, and details on a

Yes or No

regulation within the last five years?

separate page.

17.

Has any officer, director, or game manager who participates in the conduct

of any charitable gaming activity been (a) convicted of a felony in the

preceding ten years, (2) convicted of any misdemeanor involving fraud, theft

or financial crimes within the preceding five years of this application, or (3)

participated in the management, operation or conduct of any charitable

game which was found by the Office or a court of competent jurisdiction to

If Yes, please provide name,

have been operated in violation of state law, local ordinance, or Office

address, and details on a

regulation within the last five years?

Yes or No

separate page.

18.

Is any officer, director, game manager, member, or any member who

volunteers in the conduct, operation, or management of charitable gaming

activities related to a registered supplier, supplier's agent, employee,

member of the supplier's immediate family or person residing in the same

If yes, please explain and

household who offers, provides, or sells gaming products to your

provide details on a separate

Yes or No

organization?

page.

CHARITABLE GAMING ACTIVITIES

19.

List the location(s), day(s), date(s) and time(s) the charitable gaming activity(s) will be held:

(List all planned activities below. If more

space is needed or your organization utilizes additional facilities, provide the same information relative to the additional facility on a separate page and attach.)

Building Name (Where Charitable Gaming

Activities Will Be Held):

Physical Address:

City/Town:

State:

Zip Code:

Official Jurisdiction (County of/City of):

Annual Pull Tab Event -

Type of Gaming Activity -

Qualified Association,

Please an "X" by the

Stand Alone