Form Bi-60 - Initial Application For Bingo License
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1
2FOR OFFICE USE ONLY
INITIAL APPLICATION FOR BINGO LICENSE
FEE:
$25.00
KANSAS DEPARTMENT OF REVENUE
Statutory Registration Fee
Charitable Gaming
915 SW Harrison Street
LICENSE NO. _____________________
Topeka, Kansas 66625-3512
Phone: 785-296-6127
APPROVED BY:
E-mail: bingo@kdor.state.ks.us
See the Kansas Bingo Handbook, Section I - Licensed Organizations -
DATE ISSUED: ____________________
Pages 1 and 2 for information about the application process.
Mail the completed application and $25 fee to the address above.
1. Organization's name and mailing address for notices and forms:
Exact address where bingo games will be conducted:
2.
Name
_____________________________________________
Number and Street
Street, Route or P.O. Box No.
_____________________________________________
City
Zip
City
State
Zip
3. Organization's Federal Employer Identification Number (FEIN):
4
Organization's office or business phone number (include area code):
.
_
5. Member of your organization that we may contact regarding conduct of bingo games and review of records:
(
)
Name
Title
Daytime Phone Number
(
)
E-Mail Address
FAX Number
T
T
6. Will bingo games be conducted on leased or rented premises?
If yes, list lessor's bingo premises name
No
Yes
and registration number:
______________________________________________
Enclose a copy of your lease agreement.
7. Which days of the week or month will bingo games be conducted?
Exact time of day when you will start conducting bingo games: Mini games:
Regular games:
List any months of the year when you will NOT be conducting bingo games:
8. Is your organization registered to collect and remit Kansas sales tax at the location where bingo games will be conducted?
T
T
Yes If yes, enter your sales tax registration number:
No
T
T
T
T
T
9. Type of non-profit organization—check one:
Religious
Educational
Charitable
Veterans
Fraternal
10. Type of organizational entity and affiliation (check as many as apply):
T
on-profit corporation. Indicate date and state of incorporation: ___________________________
Local organization is a n
T
nincorporated, independent association or club.
Local organization is an u
T
Local organization is c
hartered by or affiliated with a state, regional or national organization. Name and address of
chartering or parent organization:
11. Number of months or years that your local organization has been in existence in Kansas:
(This applies to your specific local organization, not to any national or state organization with which you may be affiliated.)
T
T
12. Is membership in your organization denied to any person for reasons of race, color or physical handicap?
No
Yes
13. Attach a list of all current members of your organization, including their full legal name, complete address and date they
T
T
became a member. Are your members required to pay dues?
No
Yes
(Application continues on reverse side)
BI-60 (Revised January 2003)
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Parent category: Financial