Form Bi-160 - Renewal Application For Bingo License Page 2
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38. Information about the presiding officer of your organization:
Current:
Corrections:
Name
Title
Phone Number
Social Security Number
Date of Birth
Has any officer, director or official of your organization, or any person employed by your organization on the
9.
premises where bingo games are conducted been convicted of, pleaded guilty to or pleaded nolo contendere (no
contest) to violation of any gambling laws of any state or the United States or violation of any felony of this or any
other state, or forfeited bond to appear in court to answer charges for any violation of the gambling laws of any state
T
T
or the United States?
No
Yes
If yes, list name of each such person and particulars of conviction or bond forfeiture on a separate page and enclose
with to this application.
Has any person who is or will be participating in the management, conduct or operation of bingo games by this
10.
organization been convicted of or pleaded guilty or nolo contendere (no contest) to any felony or illegal gambling
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activity or purchased a tax stamp for wagering or gambling activity?
No
Yes
If yes, list name of person or persons, home address, date of birth, and particulars of offense or offenses on a
separate page and enclose with this application.
VERIFICATION OF OFFICERS OF ORGANIZATION
STATE OF KANSAS
)
) ss:
COUNTY OF
)
We, the undersigned, of lawful age, being first duly sworn, upon our oaths state:
That we are the presiding officer and secretary, respectively, of the above-named organization making
application for a bingo license; that our organization is a bona fide, non-profit organization of a type defined by
K.S.A. 79-4701 and is authorized to operate within the State of Kansas; that we have read and know the
contents of the foregoing Renewal Application for Bingo License; and that all of the answers and information
provided therein are true, correct and complete.
Signature of Presiding Officer
Signature of Secretary
Typed or Printed Name of Presiding Officer
Typed or Printed Name of Secretary
Title
Title
SUBSCRIBED AND SWORN TO before me this
day of
,
.
Notary Public
My Appointment Expires:
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