Form 201 - R - Charitable Gaming Permit Application Renewal Applicants Only Page 8
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12PERSONNEL INFORMATION
Section 18.2-340.25, Code of Virginia, 1950, as amended, provides that no charitable gaming license can be issued prior
to a reasonable investigation conducted by the Office of Charitable and Regulatory Programs.
Complete the following information for the (1) President, (2) Treasurer/Financial Officer,
or their equivalent position, and (3) Each Game Manager.
Answer each section in its entirety. FULL PROPER LEGAL NAMES must be provided -- applications with initials or
incomplete responses will delay processing of the application . If an individual has no middle name, then insert
"NMN" (No Middle Name). The social security numbers and dates of birth of all individuals must be provided in order for
this application to be considered complete.
I understand that I am required to submit a Personnel Information Update Form for any change in the Organization's
President, Treasurer/Financial Officer, or their equivalent position, or Game Manager after submission of this Renewal
Application, and immediately upon any change in any of the above designated officers. The Personnel Information
Update Form is available under "Licensing Forms" on OCRP's web site at
Position Codes: (Check the appropriate box for each applicable individual, or its equivalent position)
President/Commander/
Game Manager(s)/
Governor/Exalted Ruler, etc.
Treasurer/Financial Officer
Bingo Manager(s)
Date:
Signature:
Organization
Title:
Full Name:
Complete First Name
Complete Middle Name
Complete Last Name
Complete Term of Office Holder:
Begin Term Date:
End Term Date:
Month/Date/Year
Month/Date/Year
Date of
Social Security No.:
Birth:
Race:
Sex:
Physical Home
Address:
City:
State:
Zip Code:
Daytime Contact No.:
Fax No.:
Other Contact No.:
E-Mail Address:
NOTE: Organization's are required to submit a Personnel Information Update Form if there are any changes in the (1)
President, (2) the Treasurer/Financial officer, or its equivalent position, and (3) for any Game Manager after issuance of a
permit if the above referenced designated individuals listed in this application change or if officer elections occur. This
should be submitted as soon as the change takes place.
Prior to issuance of a license and/or permit, the VDACS Office of Charitable and Regulatory Programs reserves
the right to request additional information from those named in the "Personnel Information" section of this
Charitable Gaming Permit Application - Renewal Applicants Only.
Charitable Gaming Permit Application - Renewal Applicants Only
Rev. 07/30/13
Page 8 of 12
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