Form Bi-148 - Initial Application For Registration Of Bingo Premises
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1
2FOR OFFICE USE ONLY
INITIAL APPLICATION FOR REGISTRATION OF BINGO PREMISES
FEE
$100.00
KANSAS DEPARTMENT OF REVENUE
Statutory Registration Fee
Charitable Gaming - Room 214
915 SW Harrison Street
Topeka, Kansas 66625-3512
REGISTRATION NO:
Phone: 785-296-6127
APPROVED BY:
See the Kansas Bingo Handbook, Section II - Registered Premises -
Pages 1 and 2 for information about the application process.
DATE ISSUED: ____________________
Mail the completed application and $100 fee to the address above.
1. Lessor's name and mailing address for notices:
2.
Exact address where bingo games will be conducted:
Name
Street, Route or P.O. Box No.
City
State
Zip
3. Federal Employer Identification Number (FEIN) _________________________________________ (If none, then so indicate.)
4. Lessor's business telephone number: Area Code
(
)
T
T
T
5. 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.
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T
6. Do you now own or lease any other premises used for the conduct of Bingo?
No
Yes
If yes, list addresses of each:
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7. Do you operate a concession stand at this location?
No
Yes
If yes, enter Kansas sales tax registration number:
8. Have you or any current business associate or employee ever previously applied for a bingo premises certificate of registration?
T
T
No
Yes
If yes, indicate date and address of the premises applied for, and if a certificate of registration was issued,
the registration number:
9. Attach a sample copy of the written lease agreement which you are using for leasing this premises during the next twelve months.
The lease agreement must conform to the requirements listed in Section II and Form BI-55 in the Kansas Bingo Handbook.
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10. Are you the exclusive legal owner of the premises being registered?
No
Yes
If
any
of
such
owners
is
a
partnership or corporation, then list the partnership or corporate name here:
11. List the name, bingo license number, and days of the week scheduled for each organization that is or will be leasing this premises
from you for the conduct of bingo games:
Name of Organization
Bingo License No.
Day(s) of the Week Playing
BI-148 (Revised November 2002)
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