Form L-2168 - Application For License To Manufacture Electronic Bingo Tickets
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1
2STATE OF SOUTH CAROLINA
1350
1350
DEPARTMENT OF REVENUE
L-2168
(Rev. 12/30/08)
APPLICATION FOR LICENSE TO MANUFACTURE
4318
ELECTRONIC BINGO TICKETS
Application must be received in the Columbia Office of the Department of
FOR OFFICE USE ONLY
Revenue no later than 45 days prior to renewal date. Mail application and
General Fund $ ______________
make check payable to the South Carolina Department of Revenue,
Cash - M.O. - Check
Regulatory Division Bingo Enforcement, PO Box 125, Columbia SC 29214.
Telephone (803) 898-5393.
License No. _________________
Expiration __________________
The application must be filed in original form, and all signatures must be original.
Date License Issued __________
We cannot accept carbon or photo copy applications or stamped, traced,
facsimile or other signatures.
142561
Type of Business: Manufacturer - $1,000.00 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
UNINCORPORATED ASSOCIATION: ENTER LEGAL NAME
(one owner)
PARTNERSHIP
SC CORPORATION DATE INC.
FOREIGN CORPORATION (attach copy of articles or certificate of authority).
(two or more owners)
OTHER (explain)
7.
Provide the following information for each business Owner, Partner, or Officer. If the business is a corporation with a
parent or any subsidiary corporation, provide the following information for all stockholders of 10% or more. Under
Section 12-21-4260 of the Bingo Tax Act, a person licensed as a bingo manufacturer shall submit to a background
investigation. This includes each partner of a partnership and each director and officer and all stockholders of 10% or
more in a parent or subsidiary corporation of a bingo card manufacturer. The department has sole discretion to issue the
license based on the background investigation. If additional space is needed, please attach the additional information to
this application.
SOCIAL
IF PARTNERS/STOCKHOLDER
DATE
NAME/POSITION HELD
HOME ADDRESS
SECURITY
PERCENT OWNED
OF BIRTH
NUMBER
43181023
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