Form Bi-168 - Renewal Application For Bingo Premises (Page 2 of 2) in pdf

Form Bi-168 - Renewal Application For Bingo Premises Page 2

11. List the full name, home address and date of birth for each of the following persons involved with the premises to be registered:

a. Each individual owner and lessor.

b. If the owner or lessor is a partnership, list each partner.

c. If the owner or lessor is a corporation, list each officer and each stockholder who owns 10% or more of the capital stock of the

corporation.

d. Each person who will be involved with the premises as a paid employee of the owner or lessor or as an independent

contractor, in a management, maintenance, cleaning, security, sales or other capacity.

Complete

Social Security

Full Name/

Date of Birth

Number MUST

Type of Involvement

(Month, DAY,

be Listed

(owner, lessor, employee, etc.)

Home Address

and Year)

(Enclose a separate sheet if more space is needed)

Verification of Premises Lessor

State of

)

) ss:

County of

)

The undersigned, of lawful age, being first duly sworn, upon his or her oath, states:

That the undersigned is the lessor of the premises above described; has read and knows the contents of the above

and foregoing Renewal Application for Registration of Bingo Premises; and that the answers and information provided

therein are true, correct and complete.

Signature of Lessor

Printed or Typed Name of Lessor

Title or Position

SUBSCRIBED AND SWORN TO before me this

day of

, 200

Notary Public

My Appointment Expires:

Form Bi-168 - Renewal Application For Bingo Premises Page 2