Form Ador 71-1002f - Endorsement By Local Governing Body

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Arizona Department of Revenue • Bingo Section
Phoenix: (602) 716-7801
ENDORSEMENT BY LOCAL GOVERNING BODY
For Offi cial Use Only
To be completed by the local governing body and returned to the Bingo Section pursuant to ARS §5-404.A.
LICENSE #
DATE
New Application
Change of Location
FROM (NAME OF LOCAL GOVERNING BODY)
ADDRESS - NUMBER AND STREET, PO BOX
TELEPHONE NUMBER WITH AREA CODE
CITY
STATE
ZIP CODE
1. This is to certify that on
, a hearing was conducted pursuant to Arizona Revised Statute, Title 5,
Chapter 4, on the:
Application for a bingo license by the following applicant
Application for a bingo license location transfer
2. Name of applicant:
3. Location/address where games will be conducted:
4. Days and times of games:
Monday:
________
AM
PM
Friday:
________
AM
PM
Tuesday:
________
AM
PM
Saturday:
________
AM
PM
Wednesday: ________
AM
PM
Sunday:
________
AM
PM
Thursday:
________
AM
PM
5. Background investigations:
have
have not been conducted on all individuals listed in the Bingo License Application.
6. Recommendation: The application be
Approved
Disapproved
7. Specifi c reasons for disapproval are hereby listed pursuant to ARS §5-404.1:
NOTE: This endorsement must be signed by a delegated authority of the local governing body.
PRINTED NAME
SIGNATURE
DATE
TITLE
Mail completed, signed form to:
Arizona Department of Revenue
Bingo Section
1600 West Monroe, Room 520
Phoenix, AZ 85007
ADOR 71-1002f (4/06)
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