Form L-2057 - Application For Bingo Promoter'S License Page 3
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413A.
Ever
Promoter Name
Home Address
S.S. #
Phone #
DOB
convicted?
AFFIDAVIT
STATE OF SOUTH CAROLINA
County of
I,
,
of the
(Please Print)
(Title)
swear (or affirm) that the information contained herein
and on the attached sheets is, to the best of my knowledge and belief, true and correct, that the game of Bingo will be
conducted as outlined in Section 12-21-3910 and 12-21-3920 of the S.C. Code, and that the promoter will advise the
Department, in writing, within 30 days of any changes in the information supplied on this application.
Sworn to and subscribed before me this
day of
, 20
Signature
(Notary Public for S.C.)
If partnership, all partners must sign.
41363029
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Parent category: Financial