Form Wv/bgo-1 - Application For Annual, Limited, State Fair Or Super Bingo License (Page 3 of 3) in pdf

APPLICATION FOR ANNUAL, LIMITED, STATE FAIR OR SUPER BINGO LICENSE

WV/BGO-1

rtL175 v 10-web

SECTION 10 - NAMES OF OFFICERS OF ORGANIZATION

LIST NAMES, HOME ADDRESSES AND HOME TELEPHONE NUMBERS OF ALL OFFICERS AND MEMBERS OF THE BOARD OF

DIRECTORS, GOVERNORS OR TRUSTEES, IF ANY, IN THE ORGANIZATION. ALL OFFICERS MUST BE OVER 18. (ATTACH ADDITIONAL

SHEET IF NECESSARY)

NAME AND TITLE

HOME ADDRESS

HOME TELEPHONE NUMBER

SECTION 11 - PERSONS IN CHARGE OF BINGO

LIST NAMES, HOME ADDRESSES AND TELEPHONE NUMBERS OF PERSONS IN CHARGE OF BINGO OCCASIONS. THESE PERSONS MUST

BE BONA FIDE MEMBERS OF YOUR ORGANIZATION AND RESIDENTS OF THE STATE OF WEST VIRGINIA. ANNUAL LICENSES REQUIRE 3

NAMES. LIMITED LICENSES REQUIRE AT LEAST 2 NAMES. ONE OF THESE PERSONS MUST BE PRESENT AT ALL BINGO OCCASIONS.

ALL PERSONS IN CHARGE OF BINGO MUST BE OVER 18.

NAME AND TITLE

HOME ADDRESS

HOME TELEPHONE NUMBER

SECTION 12 - NAME OF HIGHEST ELECTED OFFICER AND APPOINTED DESIGNEE

LIST NAMES, HOME ADDRESSES AND HOME TELEPHONE NUMBERS OF THE HIGHEST ELECTED OFFICER AND HIS APPOINTED DESIGNEE OF

ORGANIZATION ONE OF THESE PERSONS MUST BE PRESENT AT ALL OCCASIONS ALL PERSONS MUST BE OVER 18

NAME AND TITLE

HOME ADDRESS

HOME TELEPHONE NUMBER

HIGHEST ELECTED OFFICER

APPOINTED DESIGNEE

SECTION 13 - YOU MUST ANSWER THE FOLLOWING QUESTIONS

Has your Bingo License Application ever been refused, denied, revoked, or suspended?

YES

Has any person in your Organization who will participate in any manner in the conduct of Bingo Games or related

YES

concessions ever been convicted of a Felony or Misdemeanor for a gambling offense within the past 10 years?

If you answered yes to any of these questions, attach a separate sheet explaining.

SECTION 14 - DISPOSITION OF PROCEEDS

Recipient of Proceeds:

Does this recipient have an Internal Revenue Service Exemption Status Letter?

YES

Intended use of Proceeds:

PLEASE NOTE: YOU MUST LIST THE NAMES OF ALL ORGANIZATIONS YOU INTEND TO DONATE PROCEEDS TO ATTACH SEPARATE SHEET IF NECESSARY

SECTION 15 - AGREEMENT

I fully understand that it is a violation of Chapter 47, Article 20 to allow anyone other than authorized persons to conduct any part of the Bingo Games or Concessions; That I am

required to file reports and keep records as provided by Article 20; That it is a crime to violate any provisions of Article 20; That a violation may result in suspension or

revocation of the license and possible denial of subsequent license applications

, AS AN AUTHORIZED REPRESENTATIVE OF

CERTIFY OR AFFIRM THAT THE STATEMENTS AND ITEMS ENTERED HEREIN AND ATTACHED HERETO ARE TRUE AND CORRECT TO THE BEST OF MY

KNOWLEDGE

(Name - Type or Print)

(Signature)

(Date)

(Telephone Number)

(Email Address)

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