Form Bi-168 - Renewal Application For Bingo Premises
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2RENEWAL APPLICATION FOR BINGO PREMISES
FOR OFFICE USE ONLY
KANSAS DEPARTMENT OF REVENUE
FEE
$100.00
Charitable Gaming
Statutory Registration Fee
Docking State Office Building - Room 214
PREMISE NO.
915 SW Harrison Street
Topeka, Kansas 66625-3512
APPR.
/ISSUED
Phone: 785-296-6127 / Facsimile: 785-296-7185
1. Lessor's Name and Mailing Address :
2. Address of location where bingo games will be conducted:
(For notices and correspondence)
3. Federal Employer Identification Number (FEIN) _________________________________________ (If none, then so indicate.)
4. Lessor's business telephone number: Area Code
(
)
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5. Type of business entity:
Sole Proprietorship
Partnership
Corporation
If incorporated, enter the date and state of incorporation:
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6. Do you currently operate any other premises used for the conduct of bingo games in Kansas?
No
Yes
If yes, list the name, address and registration number of each premises:
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7. Do you operate a concession stand at this location?
No
Yes
If yes, enter your Kansas sales tax registration number:
8. Enclose a sample copy of the written lease agreement which you are using for leasing this premises to licensed organizations
during the next twelve months.
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9. Are you the exclusive legal owner of the property where the bingo games will be conducted?
No
Yes
If not, then provide the legal name and mailing address of each person, partnership or corporation which has an ownership interest
in the property:
10. List the name and bingo license number of each organization that is currently leasing this premises from you for the conduct of
bingo games. Also list the days of the week that each is conducting bingo games:
Name of Organization
Bingo License No.
Day(s) of the Week Playing
BI-168 (Revised April 2004)
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