Form Rb-40 - List Of Bingo Workers Page 2
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1
2Step 2: List those who will participate in your games (continued)
B - ____________
13 _______________________________________________
21 _______________________________________________
Name (print or type)
Name (print or type)
_______________________________________________
_______________________________________________
Number and street
Number and street
______________________________________________
______________________________________________
City, state, ZIP
City, state, ZIP
14 ______________________________________________
22 ______________________________________________
Name (print or type)
Name (print or type)
______________________________________________
______________________________________________
Number and street
Number and street
______________________________________________
______________________________________________
City, state, ZIP
City, state, ZIP
15 ______________________________________________
23 ______________________________________________
Name (print or type)
Name (print or type)
______________________________________________
______________________________________________
Number and street
Number and street
______________________________________________
______________________________________________
City, state, ZIP
City, state, ZIP
16 ______________________________________________
24 ______________________________________________
Name (print or type)
Name (print or type)
______________________________________________
______________________________________________
Number and street
Number and street
______________________________________________
______________________________________________
City, state, ZIP
City, state, ZIP
17 ______________________________________________
25 ______________________________________________
Name (print or type)
Name (print or type)
______________________________________________
______________________________________________
Number and street
Number and street
______________________________________________
______________________________________________
City, state, ZIP
City, state, ZIP
18 ______________________________________________
26 ______________________________________________
Name (print or type)
Name (print or type)
______________________________________________
______________________________________________
Number and street
Number and street
______________________________________________
______________________________________________
City, state, ZIP
City, state, ZIP
19 ______________________________________________
27 ______________________________________________
Name (print or type)
Name (print or type)
______________________________________________
______________________________________________
Number and street
Number and street
______________________________________________
______________________________________________
City, state, ZIP
City, state, ZIP
20 ______________________________________________
28 ______________________________________________
Name (print or type)
Name (print or type)
______________________________________________
______________________________________________
Number and street
Number and street
______________________________________________
______________________________________________
City, state, ZIP
City, state, ZIP
Step 3: Sign below
Step 4: Mail your return
I hereby certify under penalties of perjury that the individuals listed
Mail your completed form to:
above will not receive any remuneration or compensation directly or
OFFICE OF BINGO AND CHARITABLE GAMES
indirectly for participating in the management or operation of any
ILLINOIS DEPARTMENT OF REVENUE
bingo games conducted by the licensed organization.
PO BOX 19480
SPRINGFIELD IL 62794-9480
___________________________________________________
If you have any questions, call our Springfield office weekdays
Presiding officer
Date
between 8:00 a.m. and 4:30 p.m. at 217 524-4164.
RB-40 (R-08/01)
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