Form L-2128 - Application For License To Manufacture Or Distribute Bingo Game Cards
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1
2STATE OF SOUTH CAROLINA
1350
1350
DEPARTMENT OF REVENUE
L-2128
(Rev. 5/22/09)
APPLICATION FOR LICENSE TO MANUFACTURE
4217
OR DISTRIBUTE BINGO GAME CARDS
Application must be received in the Columbia Office of the Department of Revenue
no later than 45 days prior to renewal date. Mail application and make check
FOR OFFICE USE ONLY
payable to the South Carolina Department of Revenue, Regulatory Division,
General Fund $
Columbia, SC 29214-0026. Telephone (803) 898-5393.
Cash-M. O.-Check
The application must be filed in original form, and all signatures must be original.
License No.
We cannot accept carbon or photo copy applications nor stamped, traced,
facsimile, or other signatures.
Expiration
Type of Business:
Date License Issued
Manufacture - $5,000.00 Fee
Distributor - $2,000.00 Fee
COMPLETE BOTH SIDES OF THIS APPLICATION
PLEASE PRINT OR TYPE ALL INFORMATION
Business phone number
Federal Identification Number
1. Business Name
Print - Do not write
2. Mailing Address
Street No. - RFD
City and State
Zip Code
3. Name of Owner
4. Business Address
Street No. - RFD
City
County
State
Zip Code
5. Location of records (No PO Box)
Name
Street No.
City and State
Zip Code
Phone Number
6. Type of ownership
SOLE PROPRIETOR
LLC/LLP
(one owner)
UNINCORPORATED ASSOCIATION: ENTER LEGAL NAME.
PARTNERSHIP
SC CORPORATION DATE INC.
(two or more owners)
FOREIGN CORPORATION (attach copy of articles or certificate of authority).
OTHER (EXPLAIN)
7. NAME(S) OF BUSINESS OWNER, PARTNERS, OR OFFICERS & STOCKHOLDERS OF TEN PERCENT OR MORE
IF PARTNER
SOCIAL SECURITY NUMBER
NAME/POSITION HELD
HOME ADDRESS
PERCENT OWNED
8.
Do you currently have a bond on file with the Department of Revenue?
Yes
No
If yes, what is the value of the bond? $
If no, you must submit a bond per Section 12-21-4230 S.C. Code.
Value of bond submitted?
$
42171025
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