Bingo Licensee'S Report Of Change In Officers, Directors, Officials Or Persons Employed On Bingo Premises
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1
2Phone: (785) 296-6127
Fax: (785) 368-8392
Kansas Department of Revenue
Hearing Impaired TTY: (785) 296-6461
915 SW Harrison St.
E-mail Address: bingo@kdor.ks.gov
Topeka, KS 66625-0001
Nick Jordan, Secretary
Sam Brownback, Governor
Department of Revenue
Patsy Congrove, Charitable Gaming
BINGO LICENSEE'S REPORT OF CHANGE IN
OFFICERS, DIRECTORS, OFFICIALS OR PERSONS EMPLOYED ON BINGO PREMISES
Instructions: Use this form to update information previously submitted to us on your license application or this form.
1.
Name of organization and location of bingo games as they appear on your bingo license:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
2.
Bingo license number: ________________________________
3.
The following are changes in the names of officers, directors or officials of this organization and all other persons who are
or will be employed by this organization on the premises where bingo games will be conducted, whether or not they are
members of this organization, and whether or not directly involved with the conduct of bingo games:
ADDITIONS
Title or position__________________________ Full name_________________________________ SSN__________________
Home address____________________________________________________________________________________________
Phone________________________ E-mail________________________ Fax_____________________ Date of birth_________
Title or position__________________________ Full name_________________________________ SSN__________________
Home address____________________________________________________________________________________________
Phone________________________ E-mail________________________ Fax_____________________ Date of birth_________
Title or position__________________________ Full name_________________________________ SSN__________________
Home address____________________________________________________________________________________________
Phone________________________ E-mail________________________ Fax_____________________ Date of birth_________
Title or position__________________________ Full name_________________________________ SSN__________________
Home address____________________________________________________________________________________________
Phone________________________ E-mail________________________ Fax_____________________ Date of birth_________
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