Form Bi-60 - Initial Application For Bingo License Page 2
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14. Does your organization have a tax-exempt ruling from the Internal Revenue Service?
No
Yes If yes, enclose
a copy of most recent IRS letter verifying such ruling. If your organization is covered by a group ruling issued to a national,
state or other parent organization, then enclose a letter from the state or parent organization verifying that fact.
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15. Has your organization ever been issued a bingo license?
No
Yes
If yes, list the license number and date
of issue: License No.
Date issued:
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16. Has your organization ever been denied a bingo license or had a bingo license revoked?
indicate
No
Yes
If yes,
date and reason for denial or revocation:
17. List in the space below the following persons, whether or not they are directly involved with the conduct of bingo games:
(a) All directors and principal officers of your organization.
(b) All paid employees of your organization who are or will be working at the premises where bingo games are conducted,
whether or not they are also members of your organization.
Complete
Social Security
Date of Birth
Number MUST
Full Legal Name
Title or Position
Complete Home Address
(Month, DAY,
be Listed
(including city)
and Year)
18. Has any of the persons listed above been convicted of, pleaded guilty to or pleaded nolo contendere (no contest) to violation
of any gambling laws of any state or the United States or violation of any felony of this or any other state, or forfeited bond to
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appear in court to answer charges for violation of the gambling laws of any state or the United States?
No
If yes, list name of each such person and particulars of conviction or bond forfeiture on a separate page and enclose with
this application.
19. Has any person who is or will be participating in the management, conduct or operation of bingo games by this organization
been convicted of or pleaded guilty or nolo contendere (no contest) to any felony or illegal gambling activity or purchased a
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tax stamp for wagering or gambling activity?
No
Yes
If yes, list name of person or persons, home address,
date of birth, and particulars of offense or offenses on a separate page and enclose with this application.
VERIFICATION OF OFFICERS OF ORGANIZATION - MUST BE SIGNED AND NOTARIZED
STATE OF KANSAS
)
) ss:
COUNTY OF
)
We, the undersigned, of lawful age, being first duly sworn, upon our oaths state:
That we are the presiding officer and secretary, respectively, of the above-named organization making application for a
bingo license; that our organization is a bona fide, non-profit organization of a type defined by K.S.A. 79-4701 and is authorized
to operate within the State of Kansas; that we have read and know the contents of the foregoing Initial Application for Bingo
License; and that all of the answers and information provided therein are true, correct and complete.
Signature of Presiding Officer
Signature of Secretary
Typed or Printed Name of Presiding Officer
Typed or Printed Name of Secretary
Title
Title
SUBSCRIBED AND SWORN TO before me this
day of
,
.
Notary Public
My Appointment Expires:
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