Form Ador 71-1010f - Application For Bingo License Page 2
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5ARIZONA DEPARTMENT OF REVENUE
APPLICATION FOR BINGO LICENSE
8 Class B and Class C license applicants only: If applying as a qualifi ed organization, list current offi cers:
NAME
NAME
8a
8b
TITLE
TITLE
ADDRESS - NUMBER AND STREET, RURAL RT., APT. NO.
ADDRESS - NUMBER AND STREET, RURAL RT., APT. NO.
CITY
STATE
ZIP CODE
CITY
STATE
ZIP CODE
NAME
NAME
8c
8d
TITLE
TITLE
ADDRESS - NUMBER AND STREET, RURAL RT., APT. NO.
ADDRESS - NUMBER AND STREET, RURAL RT., APT. NO.
CITY
STATE
ZIP CODE
CITY
STATE
ZIP CODE
9 Class B and Class C license applicants only: Bingo checking account information:
Checking Account Number:
Bank Name and Branch:
10 Class B and Class C license applicants only: Bingo interest-bearing account information:
Account Number:
Bank Name and Branch:
11 Class B and Class C license applicants only: List all offi cers and/or supervisors authorized to sign checks from the
accounts listed above. If applying as a qualifi ed organization, all supervisors must be members of the applicant:
NAME
NAME
11a
11b
TITLE
TITLE
ADDRESS - NUMBER AND STREET, RURAL RT., APT. NO.
ADDRESS - NUMBER AND STREET, RURAL RT., APT. NO.
CITY
STATE
ZIP CODE
CITY
STATE
ZIP CODE
12 List the name(s) of the one or two persons who will serve as managers. If applying as a qualifi ed organization, these persons
must be members of the applicant. Each person must submit an affi davit.
NAME
NAME
12a
12b
TITLE
TITLE
ADDRESS - NUMBER AND STREET, RURAL RT., APT. NO.
ADDRESS - NUMBER AND STREET, RURAL RT., APT. NO.
CITY
STATE
ZIP CODE
CITY
STATE
ZIP CODE
13 List the name of the one person designated as proceeds coordinator. If applying as a qualifi ed organization, this person must be
an offi cer or director and a member of the applicant. Each person must submit an affi davit.
NAME
ADDRESS - NUMBER AND STREET, RURAL RT., APT. NO.
TITLE
CITY
STATE
ZIP CODE
ADOR 71-1010 (4/06)
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Parent category: Financial