Form Bi-158 - Initial Application For Registration Of Bingo Distributor
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4INITIAL APPLICATION FOR REGISTRATION OF BINGO DISTRIBUTOR
FOR OFFICE USE ONLY
KANSAS DEPARTMENT OF REVENUE
FEE:$500.00 Reg. Fee + $1,000 Tax Bond
Charitable Gaming - Room 214
DISTR. NO.:
915 SW Harrison Street
Topeka, Kansas 66625-3512
APPR.:
/ISSUED
Phone: 785-296-6127
1. Business name and mailing address for notices and tax
2. Actual business location address:
forms:
Name
Street, Route or PO Box
City
State
Zip
3. Federal Employer Identification Number (FEIN). If none, then so indicate.
4. Type of business entity:
Sole Proprietorship
Partnership
Corporation
If incorporated, enter the date and
state of incorporation:
Enclose a copy of the Articles of Incorporation if
this is your initial application or if you have incorporated since the last time you renewed.
5. List names and addresses of all offices, manufacturing and storage locations where your bingo records of sales to Kansas licensees
are kept and locations which will be involved in distributing disposable paper bingo cards or instant bingo tickets in Kansas. Use a
separate sheet if necessary.
6. Full name, mailing address, and telephone number of person who will maintain records of sales of disposable paper cards and
instant bingo tickets in Kansas:
Name
Telephone No.
(
)
Address
City
ST
Zip
7. If owner(s) or corporate officers are not residents of Kansas, list name and address of the person within the state of Kansas
authorized to receive service of legal process:
Name
Telephone No.
(
)
Address
City
ST
Zip
8. Ownership Information - List the name, address, social security number, complete date of birth, home telephone number and title
of all owners, partners, corporate officers or directors. Enclose a separate sheet if necessary.
-
-
/
/
a) Name
SSN
DOB
Home Address
City
ST
Zip
(
)
Home Telephone
Ownership Title
-
-
/
/
b) Name
SSN
DOB
Home Address
City
ST
Zip
(
)
Home Telephone
Ownership Title
-
-
/
/
c) Name
SSN
DOB
Home Address
City
ST
Zip
(
)
Home Telephone
Ownership Title
-
-
/
/
d) Name
SSN
DOB
Home Address
City
ST
Zip
(
)
Home Telephone
Ownership Title
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