Form 201 - R - Charitable Gaming Permit Application Renewal Applicants Only Page 4
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12CHARITABLE GAMING ACTIVITIES
21.
(If more space is needed or your organization utilizes additional facilities, provide the
FOR ALL CHARITABLE GAMING ACTIVITIES:
same information relative to the additional facility on a separate page and attach.)
a.
Who owns and has title to the facility where the charitable gaming
Organization
Yes or No
activities will occur. Check one.
Leased
Yes or No
Other - Explain:
If the applicant organization does not own and have title to the facility,
attach a copy of the current lease that authorizes the organization to
use the facility in the conduct of charitable gaming activities, including
Is lease
bingo and raffle(s).
Yes or No
attached?
b.
Is the equipment used to conduct the charitable gaming activities
owned or leased by the applicant organization? If leased, list the
Owned?
Yes or No
name, address, and contact number of the lessor of the equipment.
If leased, attach a separate page with the name of the owner, address, and
Leased?
Yes or No
contact number.
c.
Landlord Full Name:
Landlord Address:
City:
State:
Zip Code:
Contact Person:
Telephone:
Facility
d.
Name of Facility:
Manager:
Facility Telephone:
Facility Facsimile:
22.
Are the premises used by more than one organization for the purpose of conducting
charitable gaming activities? If yes, please provide the name and address of each
organization utilizing this facility on a separate page.
Yes or No
Yes
23.
For Raffle Applications Only - Will the raffle event be held in conjunction with a casino or Las Vegas
night? Please complete the following for each scheduled raffle.
Yes or No
a.
What date does the organization plan to begin raffle ticket sales?
Tickets cannot be sold until receipt of a valid charitable gaming permit.
Month/Date/Year
Raffle drawing date and time of drawing.
Month/Date/Year
Time
b.
What is the prize to be given away? Use a separate page if needed.
c.
Were the prize(s) purchased and/or donated?
(Use separate page if necessary. Check one box for each prize as to prize being
purchased or donated.) Please indicate fair market value of each prize.
$
Purchased
Yes or No
$
Purchased
Yes or No
Donated
Yes or No
Donated
Yes or No
d.
What is the total purchase price per ticket? (
.) Attach a
Use separate page if necessary
copy of each sample raffle ticket. See. 11 VAC 15-22-70.C. for required
$
information.
e.
Will volunteers/members who sell raffle tickets be allowed to buy raffle tickets? If
Yes or No
yes, please provide a detailed explanation.
f.
Provide a narrative detailing how the raffle will be conducted, its scope, who will be
Copy
responsible for its oversight, and all rules of play, i.e ., what happens if not enough
attached?
Yes or No
tickets are sold or how many days a winner has to claim the prize.
Charitable Gaming Permit Application - Renewal Applicants Only
Rev. 07/30/13
Page 4 of 12
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