Form 201 - R - Charitable Gaming Permit Application Renewal Applicants Only Page 9
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12THE PRESIDENT/CHIEF OFFICER, OR DESIGNEE, OF THE APPLICANT
ORGANIZATION MUST PRINT HIS/HER NAME, AFFIX HIS/HER SIGNATURE,
AND PROVIDE THE DATE.
I hereby certify that all information provided in this application and attachments are true to the best of my
knowledge, information and belief, that I have not knowingly made a false statement of material fact on this
application, and that I have read and understand the terms and conditions as set out under the Code of Virginia
and the VDACS Office of Charitable and Regulatory Programs Rules and Regulations. I understand that
untruthful or misleading answers are cause for denial of the charitable gaming permit. I also agree that the
organization listed on this application and its officers, directors, members, and employees, will abide by all rules
and regulations of the Department in the operation, management, and conduct of bingo game(s) and/or raffle(s)
pursuant to the Code of Virginia, Chapter 8, Section 18.2-340.15, et seq.
Signature:
Date:
Organization
Full Name:
Title:
Complete First Name
Complete Middle Name
Complete Last Name
Charitable Gaming Permit Application - Renewal Applicants Only
Rev. 07/30/13
Page 9 of 12
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