Form L-2057 - Application For Bingo Promoter'S License

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STATE OF SOUTH CAROLINA
1350
1350
DEPARTMENT OF REVENUE
L-2057
APPLICATION FOR BINGO PROMOTER'S LICENSE
(Rev. 10/12/09)
For the Year of
4136
Fee Due of $1000.00
Do Not Write in This Space
General fund $
This application must be received in the Columbia office of the Department of Revenue no
Cash-M. O.-Check
later than 45 days prior to renewal date. Mail application and make check payable to the
South Carolina Department of Revenue, Regulatory Division, Columbia, SC 29214-0026.
Audited by
Date
The application must be filed in original form, and all signatures must be original. We cannot
accept carbon or photo copy applications nor stamped, traced, facsimile, or other signatures.
File #
Expiration
Type of Ownership
Individual
Partnership
Corporation
14-2561
1. Name of Applicant
SS# or FEI#
Street Address
City
State
Zip
Mailing Address
City
State
Zip
Telephone #
Date of Birth
2. This license is to promote the Bingo Game for the following nonprofit organization:
Name as Chartered
File Number
Street Address
Street (No P.O. Box)
City
State
Zip
Location of Game
Street Address
Street (No P.O. Box)
City
State
Zip
County
Attach a copy of the contract between you and the nonprofit organization which names you as promoter.
3. Are you leasing or renting any equipment, furniture, fixtures or building to the nonprofit organization?
Yes
No
If yes, you must attach a copy of the lease or rental agreement stating the lease or rental amount and copy of
Floor Plan. Your Sales Tax License number is
4. Are you leasing/renting the building used for bingo from any individual or organization?
Yes
No
If yes, you must attach a copy of the lease or rental agreements stating the lease or rental amounts.
5. Are you a party to any contract involving use of building other than the operation of bingo?
Yes
No
If yes, you must attach a copy of the lease or rental agreements stating the lease or rental amounts.
6. How many Promoter's licenses do you currently hold?
Note: PROVIDE A COPY OF PROFESSIONAL SOLICITOR'S LICENSE FROM SC SECRETARY OF STATE.
7. Do you have any other applications for Promoter's licenses pending?
Yes
No If yes, how many?
41361023

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