Form L-2058 - Application For Bingo License Non Profit Organization Page 3
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417. Per Section 12-21-4090 of the Bingo Act, give name, address of financial institution, and account number of
special accounts.
Bingo Checking Account (Required)
Name of financial institution
Address
Street
City
State
Zip
Account Number
Bingo Savings Account (Optional)
Name of financial institution
Address
Street
City
State
Zip
Account Number
Organizational(s) Operating Checking Account (Required)
Name of financial institution
Address
Street
City
State
Zip
Account Number
Organizational(s) Operating Savings Account (Optional)
Name of financial institution
Address
Street
City
State
Zip
Account Number
18. Provide the following information for all partners, officers of the organization and stockholders of ten percent or more:
DOB
Position Held
Name
Home Address
S.S. #
Phone #
Attach additional sheet, if necessary.
19. Provide the name(s) of individual authorized to pick-up Bingo Vouchers:
Name
Home Address
S.S. #
D.L. #
DOB
41373028
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Parent category: Financial