Form 50 - Nebraska Schedule I - Bingo License
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NEBRASKA SCHEDULE
— Bingo License
FORM 50
Schedule I
Name of Organization as Shown on Form 50
PLEASE DO NOT WRITE IN THIS SPACE
PRINT FORM
Nebraska ID Number
RESET FORM
1 Type of Application
New
Report Changes (Complete only changed
(Attach to Form 50)
information and provide appropriate signatures.)
BINGO LOCATION
2 Location Name
Street Address
City
State
Zip Code
County
3 Location Is
4 Leased
Owned
Leased
(If leased, attach a copy of the lease greement. Verbal lease agreements must be put into writing.)
$
per
If Leased, Lessor's Name and Address
5 Name
Street Address
City
State
Zip Code
County
BINGO EQUIPMENT
6 Bingo Equipment Is
7 Leased
Owned
Leased
(If leased, attach a copy of the lease greement. Verbal agreements must be put into writing.)
$
per
If Leased, Lessor's Name and Address
8 Name
Street Address
City
State
Zip Code
County
9 Bingo Paper Prices and Electronic Bingo Card Monitoring Devices
Class II License Applicants Only —
Attach a separate sheet which indicates the price charged for each single sheet, packet, or book of bingo paper sold at your bingo
occasions. You must include the type of packet or single sheet (for example, 9-on 13-up packet), price charged, and color, if applicable.
Class I and Class II License Applicants — Do you intend to use electronic bingo card monitoring devices at your organization’s bingo occasions?
YES
NO
If Yes, attach a separate sheet which indicates the prices charged for each single sheet, packet, or book of bingo paper available for play
on an electronic bingo card monitoring device.
BINGO OCCASIONS
10 Frequency
(1)
Once a week
(2)
Twice a week
(3)
Other
If Other, Explain:
12 Is any organization co-sponsoring?
11 Day of Week
Time First Number Called
Ending Time
YES
NO
To
13 Name of Co-sponsor
To
14 Co-sponsor’s Nebraska ID Number
To
BINGO CHAIRPERSON
15 Social Security Number
Name of Bingo Chairperson
Street Address
Date of Birth
City
Zip Code
Years a Member
State
I declare that I will be responsible for compliance with all of the provisions of the Nebraska Bingo Act and all regulations adopted
under this Act. I further declare that I am not connected with, interested in, or otherwise concerned directly or indirectly with any business
licensed as a manufacturer or distributor of bingo equipment and/or pickle cards in Nebraska.
sign
here
Signature of Bingo Chairperson
Date
Daytime Telephone Number
MEMBERS DESIGNATED AS ALTERNATE BINGO CHAIRPERSON
16 Please attach a sheet showing a maximum of three names, addresses, Social Security numbers, years of membership, and dates of birth.
SIGNATURE OF OFFICER
Under penalties of law, I declare that I have examined this schedule and to the best of my knowledge and belief, it is correct and
sign
complete. I will comply with all of the provisions of the Nebraska Bingo Act and the regulations adopted under this Act.
here
Signature of Officer Listed on Line 15 of Form 50
Title
Date
Daytime Telephone Number
or Person Authorized by Power of Attorney
Mail the original schedule to: NEBRASKA DEPARTMENT OF REVENUE, CHARITABLE GAMING DIVISION, PO BOX 94855, LINCOLN, NE 68509-4855.
Mail a copy of this schedule to the city or county clerk. Retain a copy for your records.
6-2011
9-034-1987 Rev.
Supersedes 9-034-1987 Rev. 11-2008
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