Form Ar-1r-Brdm - Bingo Raffle Registration Distributor And Manufacturer Supplemental Form

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ARKANSAS DEPARTMENT OF FINANCE AND ADMINISTRATION

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AR-1R-BRDM

Bingo Raffle Registration Distributor and Manufacturer Supplemental Form

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SECTION A: OWNERSHIP INFORMATION

1) Legal Name (Enter full legal name of business):

2) Federal Identification Number (FEIN):

Social Security Number (SSN):

SECTION B: LICENSE TYPE

3) Type of License:

(check the appropriate box)

Original

Renewal*

A) $2,500.00 Manufacturer Annual Fiscal License

B) $2,500.00 Distributor Annual Fiscal License

*If renewal application, supply existing 8 digit Account ID

-BRR

SECTION C: RESPONSIBLE PARTY CERTIFICATION

4) I certify that as the responsible party for the above mentioned business, that I have not been found guilty or plead guilty to a felony in the State of Arkansas, or any similar

offense by a court in another state or of any similar offense by a military or federal court.

(Print Name)

(Signature of Responsible Party)

Date

Revised 03/19/2012