Form Bi-160 - Renewal Application For Bingo License printable pdf download

Form Bi-160 - Renewal Application For Bingo License

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)

Form Bi-160 - Renewal Application For Bingo License