Form Ador 71-1010f - Application For Bingo License
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5Arizona Department of Revenue • Bingo Section
Phoenix: (602) 716-7801
APPLICATION FOR BINGO LICENSE
Complete all information on this form. If you do not complete all information, your application will be returned. All information
is subject to verifi cation. If you need more space, attach additional sheets.
Falsifi cation of information contained in this application constitutes a Class 6 felony.
All bingo licenses expire one year from the date of issue. To continue conducting bingo games, you must renew your
license prior to the expiration date.
For Department of Revenue Use Only
REVIEWER’S NAME (please print)
DATE
Approved
Disapproved
License Classifi cation:
Class A
Class B
Class C
LICENSE NUMBER
TERM OF LICENSE:
From:
To:
Type or print in black ink.
1
APPLICANT’S NAME
2
TELEPHONE NUMBER WITH AREA CODE
3a ADMINISTRATIVE OFFICE LOCATION
4a MAILING ADDRESS
3b CITY
STATE
ZIP CODE
4b CITY
STATE
ZIP CODE
5 Class B and Class C license applicants only: If applying as a qualifi ed organization, indicate the type of organization:
Check one box:
Charitable
Social
Religious
Veterans
Fraternal
Volunteer Fire Department
Homeowners Association
Nonprofi t Ambulance Service
6 Class B and Class C license applicants only: If applying as a qualifi ed organization, give the name and address of your one
parent or auxiliary:
PARENT
AUXILIARY
6a
6b
ADDRESS - NUMBER AND STREET, RURAL RT., APT. NO.
ADDRESS - NUMBER AND STREET, RURAL RT., APT. NO.
CITY
STATE
ZIP CODE
CITY
STATE
ZIP CODE
7 Class B and Class C license applicants only: If applying as a qualifi ed organization, indicate the date your organization was
established in Arizona:
ADOR 71-1010f (4/06)
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