ARKANSAS DEPARTMENT OF FINANCE AND ADMINISTRATION
Print Form
AR-1R-BRLAO
Bingo and Raffle Registration Licensed Authorized Organization Supplemental Form
Clear Form
SECTION A: OWNERSHIP INFORMATION
1) Legal Name (Enter full legal name of organization):
-
2) Federal Identification Number (FEIN):
SECTION B: EVENT LOCATION INFORMATION
3) Location of event(s):
Address
City
State
Zip
Check the appropriate box:
Premises are owned by the organization
Premises are leased/rented by the organization - (Attach copy of lease agreement)
(explain):
Other
SECTION C: LICENSE TYPE
4) Type of License:
(check the appropriate box)
Original
Renewal*
A) $100.00 Annual fiscal license to operate games of bingo and raffle
B) $25.00 Temporary license to conduct one bingo session
C) $25.00 Class I temporary license to conduct one raffle
D) $10.00 Class II temporary license to conduct one raffle
(Prize donated and has a value less than $5,000.00)
*If renewal application, supply existing 8 digit Account ID
-BRR
SECTION D: NON-PROFIT CERTIFICATION AND EVENT INFORMATION
5) Is the organization incorporated under 26 U.S.C. Section 501?
Yes - Attach a copy of acceptance and approval letter from the US Internal Revenue Service reflecting 5 years of non-profit status. Additional information will be
required if less than 5 years.
No - Attach documents supporting requirement that applying non-profit organization has been in existence a minimum of 5 years.
6) Indicate the type of organization and date organized:
Religious
Service
Veterans
Educational
Medical
Volunteer Fire/Rescue
Fraternal
Governmental
Volunteer Police
7) List the charitable purpose(s) of net proceeds from Bingo/Raffle events:
8) Annual license - Enter event times the organization will operate bingo. Note: Organizations are limited to 2 bingo events per week which last no more than 5 hours each.
Sunday
Tuesday
Thursday
Saturday
to
to
to
to
Monday
Wednesday
Friday
to
to
to
9) Temporary license - Enter date which the temporary Bingo/Raffle session will be held:
SECTION E: RESPONSIBLE PARTY CERTIFICATION
10) I certify that as the responsible party for the above mentioned organization, 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 03/23/2012
1
