Form Bi-178 - Renewal Application For Bingo Distributors Page 2
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28. Employee Information - List the name, address, social security number, complete date of birth, home telephone number and title of
each employee of the applicant, including salespeople operating as independent contractors or subcontractors of the applicant.
Enclose a separate sheet if necessary.
a) Name
SSN
DOB
-
-
/
/
Home Address
City
ST
Zip
Home Telephone
Employment Title
(
)
b) Name
SSN
DOB
-
-
/
/
Home Address
City
ST
Zip
Home Telephone
Employment Title
(
)
c) Name
SSN
DOB
-
-
/
/
Home Address
City
ST
Zip
Home Telephone
(
)
Employment Title
9. Has any of the persons listed in items 7 and 8 been convicted of, pleaded guilty to, or pleaded nolo contendere (no contest) to, any
felony or illegal gambling violation in any state or the United States or any other country?
No
Yes
If yes, list name of each such person and particulars on a separate page and enclose it to this
application.
State of
)
) ss.
County of
)
The undersigned, of lawful age, being first duly sworn, upon his or her oath, states:
That the undersigned has read and knows the contents of the above Renewal Application for Bingo
Distributors and that the answers and information provided therein are true, correct and complete.
Signature of Owner, Partner or Corporate Officer
Printed or Typed Name
Title or Position
SUBSCRIBED AND SWORN TO before me this
day of
, 200
.
Notary Public
My Appointment Expires:
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