Form Bi-160 - Renewal Application For Bingo License

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FOR OFFICE USE ONLY
RENEWAL APPLICATION FOR BINGO LICENSE
FEE
$25.00
KANSAS DEPARTMENT OF REVENUE
Statutory Registration Fee
Customer Relations – Bingo Licensing Segment
LICENSE NO.
915 SW Harrison St.
Topeka, Kansas 66625-2073
APPR.
/ISSUED
In Topeka: (785) 368-8222 / Outside Topeka: 1-877-526-7738
The sections below are preprinted with the current information the Department of Revenue has for your organization. To
make corrections cross out the wrong information, and correct it to the right of the incorrect item. See additional
instructions enclosed.
1. Organization’s phone number:
2. Organization’s Federal Employer Identification Number (EIN):
(If you do not have an EIN, then write ‘None”)
3. Full address where bingo games are conducted:
Current:
Corrections:
4. Are the bingo games conducted on leased premises (N = No; Y = Yes):
5. If yes, indicated the premises registration number:
6. Days of the week that bingo games are conducted and the starting time of the first call bingo game of each session:
Current:
Corrections:
7. Information about the person in charge of your organization’s bingo operations:
Current:
Corrections:
Name
Title
Phone Number
Fax Number
E-mail Address
Social Security Number
Date of Birth
(Application continues on reverse side)
BI-160 (Rev. 5/01)

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