Form 201 - R - Charitable Gaming Permit Application Renewal Applicants Only Page 5
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12CHARITABLE GAMING ACTIVITIES
24.
Are all raffle tickets scheduled to be sold in the Commonwealth of Virginia? If no, provide
an explanation of how raffle sales will be conducted if not sold in Virginia.
Yes or No
Yes
25.
Full name of person responsible for filing financial reports:
First
Middle
Last
Relationship to Organization:
Street Address:
City:
State:
Zip Code:
Telephone:
Email Address:
Facsimile:
Where are the financial records stored?
26.
Organization
Other
Physical Address:
City:
State:
Zip Code:
Telephone:
Contact Person Full Name:
Facsimile:
First Name
Middle Name
Last Name
27.
Please list the name of any and all individuals and/or registered suppliers
who have offered and/or sold gaming supplies to your organization during
Have all suppliers of gaming
the last 12 months, or who the organization anticipates obtaining charitable
products utilized by your
gaming supplies from. Use additional sheet if necessary.
Yes or No
organization been identified?
a.
Yes
Supplier Name:
b.
Supplier Name:
c.
Supplier Name:
28.
Does the organization pay or anticipate paying any caller or bingo manager
If yes, please list each individual
for participating in the organization's charitable gaming activities? Use
below and the individual's current
additional pages if necessary.
Yes or No
BMR/BCR #.
Full Name of Individual
Title
Caller, Manager or Both
BMR/BCR #
Full Name of Individual
Title
Caller, Manager or Both
BMR/BCR #
29.
Describe in detail how the funds derived from the organization's charitable gaming activities will be disbursed in accordance with
those lawful religious, charitable, community or educational purposes.
Charitable Gaming Permit Application - Renewal Applicants Only
Rev. 07/30/13
Page 5 of 12
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