12. List the full name, home address and date of birth for each of the following persons involved with the premises to be registered:
a. Each individual owner and lessor.
b. If the owner or lessor is a partnership, list each partner.
c. If the owner or lessor is a corporation, list each officer and each stockholder who owns 10% or more of the capital stock of the
corporation.
d. Each person who will be directly involved with the bingo operations as a paid employee or agent of the owner or lessor.
Complete
Social Security
Full Name/
Date of Birth
Number MUST
Type of Involvement
(Month, DAY,
be Listed
(owner, lessor, employee, etc.)
Home Address
and Year)
(Attach separate sheet if more space is needed)
Verification of Lessor
State of
)
) ss:
County of
)
The undersigned, of lawful age, being first duly sworn, upon his or her oath, states:
That the undersigned is the lessor of the premises above described; has read and knows the contents of the above and foregoing
Application for Initial Registration of Bingo Premises; and that the answers and information provided therein are true, correct and
complete.
Signature of Lessor
Printed or Typed Name of Lessor
Title or Position
SUBSCRIBED AND SWORN TO before me this
day of
,
.
Notary Public
My Appointment Expires: