Form Bi-178 - Renewal Application For Bingo Distributors
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1
2RENEWAL APPLICATION FOR BINGO DISTRIBUTORS
FOR OFFICE USE ONLY
KANSAS DEPARTMENT OF REVENUE
FEE
$500.00
Statutory Registration Fee
Charitable Gaming
Docking State Office Building - Room 214
DISTR. NO.
915 SW Harrison Street
APPR.
/ISSUED
Topeka, Kansas 66625-3512
Phone: 785-6127 / Facsimile: 785-296-7185
1. Distributor's name and mailing address:
2. Actual business location address:
3. Federal Employer Identification Number (FEIN). If none, then so indicate.
4. List names and addresses of all offices, manufacturing and storage locations where your bingo records of sales to Kansas licensees
are kept and locations which will be involved in distributing disposable paper bingo cards or instant bingo tickets in Kansas. Use a
separate sheet if necessary.
5. Full name, mailing address, and telephone number of person who will maintain records of sales of disposable paper cards and
instant bingo tickets in Kansas:
Name
Telephone No.
(
)
Address
City
ST
Zip
6. If owner(s) or corporate officers are not residents of Kansas, list name and address of the person within the state of Kansas
authorized to receive service of legal process:
Name
Telephone No.
(
)
Address
City
ST
Zip
7. Ownership Information - List the name, address, social security number, complete date of birth, home telephone number and title
of all owners, partners, corporate officers or directors. Enclose a separate sheet if necessary.
a) Name
SSN
DOB
-
-
/
/
Home Address
City
ST
Zip
Home Telephone
(
)
Ownership Title
b) Name
SSN
DOB
-
-
/
/
Home Address
City
ST
Zip
Home Telephone
Ownership Title
(
)
c) Name
SSN
DOB
-
-
/
/
Home Address
City
ST
Zip
Home Telephone
Ownership Title
(
)
d) Name
SSN
DOB
-
-
/
/
Home Address
City
ST
Zip
Home Telephone
Ownership Title
(
)
BI-178 (Rev. March 2004)
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