Form Ador 71-1010f - Application For Bingo License Page 5
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5ARIZONA DEPARTMENT OF REVENUE
APPLICATION FOR BINGO LICENSE
21 Expected Bingo Expenses, continued...
f Bingo Supplies:
$
per _______________
PAYABLE TO
ADDRESS - NUMBER AND STREET, RURAL RT., APT. NO.
TELEPHONE NUMBER WITH AREA CODE
CITY
STATE
ZIP CODE
g Maximum prize payout per occasion: $________________. Attach game schedule that lists individual prize amounts.
PAID TO
ADDRESS - NUMBER AND STREET, RURAL RT., APT. NO.
TELEPHONE NUMBER WITH AREA CODE
CITY
STATE
ZIP CODE
h Utilities Expenses:
ELECTRIC (payable to)
ADDRESS - NUMBER AND STREET, RURAL RT., APT. NO.
ACCOUNT NUMBER
MONTHLY AMOUNT
CITY
STATE
ZIP CODE
$
GAS (payable to)
ADDRESS - NUMBER AND STREET, RURAL RT., APT. NO.
ACCOUNT NUMBER
MONTHLY AMOUNT
CITY
STATE
ZIP CODE
$
WATER (payable to)
ADDRESS - NUMBER AND STREET, RURAL RT., APT. NO.
ACCOUNT NUMBER
MONTHLY AMOUNT
CITY
STATE
ZIP CODE
$
TRASH REMOVAL (payable to)
ADDRESS - NUMBER AND STREET, RURAL RT., APT. NO.
ACCOUNT NUMBER
MONTHLY AMOUNT
CITY
STATE
ZIP CODE
$
22 Briefl y state the specifi c projected use of net proceeds from games of bingo:
Under penalty of perjury, upon oath, I, ______________________________________, declare that I am duly authorized to sign
and fi le this application. I hereby swear or confi rm that I have read the foregoing application and know the contents thereof, and
that all information provided has been fully, accurately, and truthfully completed to the best of my knowledge.
AFFIANT’S SIGNATURE
DATE
TITLE
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ADOR 71-1010f (4/06)
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