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Lancaster Bingo License Application

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Lancaster Bingo License Application Powered By Docstoc
					                                                                                                 44933 Fern Avenue
                                                                                                 Lancaster, CA 93534-2461
                                                                                                 (661) 723-6237


                                              Application for Bingo License

Type of Application:             New Application      License Renewal (Application to be filed 60 days prior to the
                              conduct of any Bingo game.)

Full Name of Non-Profit Charitable Organization:

Organization Address (No P.O. Boxes)

          City                                                                  State                         Zip Code

Organization Telephone # (             )         -            Alternate Organization Telephone # (        )         -

Purpose of Organization:




State Tax Exempt Number:

Full Name of Owner, Partners, or Principal Officers   Complete Home Address (or Corporate Address)                  Telephone #

                                                                                                                    (       )       -

                                                                                                                    (       )       -

                                                                                                                    (       )       -

                                                                                                                    (       )       -

                                                                                                                    (       )       -

                  (Please use an asterisk * by those officers to accept service of legal process on behalf of licensee.)
Bingo Manager:         Name:
     Address:                                                                                 Telephone Number: (       )       –

Bingo Manager:         Name:
     Address:                                                                                 Telephone Number: (       )       –

Bingo Manager:         Name:
     Address:                                                                                 Telephone Number: (       )       –


     1.   Neither the Bingo Manager nor the members of the non-profit organization which operate any bingo game organized
          by such organization will receive any profit, wage, or salary from any bingo game.
     2.   The Bingo Manager applicant has read and understands all requirements of the law in regard to conducting bingo
          games in the City, and that such Bingo Manager will accept full responsibility for the conduct of such bingo games
          and all members who will operate and staff the bingo games.
Signature(s): (Each designated Bingo Manager must sign.)


SIGNATURE


SIGNATURE


SIGNATURE


Names of All Members of Applicant Organization Who Will Staff Bingo Games:
Full Name of Members                           Complete Home Address (or Corporate Address)            Telephone #

                                                                                                       (     )       -

                                                                                                       (     )       -

                                                                                                       (     )       -

                                                                                                       (     )       -

                                                                                                       (     )       -

Detailed Schedule of Each Game:
Dates:                 to                             Hours:                 to
Address:                                                       Location:
Dates:                 to                             Hours:                 to
Address:                                                       Location:
Dates:                 to                             Hours:                 to
Address:                                                       Location:
Dates:                 to                             Hours:                 to
Address:                                                       Location:


Date Bingo Games to Begin:

Description of the record system to account for receipts, prizes, expenses and profits of each bingo game:




Bank Account Required by Section II:
Location:                                                           Signatures:


Location:                                                           Signatures:


If Applicant is a Trust:

Name of Trust                                  Address of Trustee                                      Telephone #

                                                                                                       (     )       -
List specific charitable purposes the proceeds will benefit:




Person to Contact for Information on Weekdays:
Name                                           Address                                                     Telephone #

                                                                                                           (      )      -

                                                                                                           (      )      -

Attached to this Application and on file with the City of Lancaster is a true and correct copy of:
    1.   State Franchise Tax Board letter or other evidence showing applicant is exempted from payment of bank and
         corporation tax by Section 23701 of the Revenue and Taxation Code.
    2.   Bank Signature Card.


APPLICANT MUST, WITHIN FIVE (5) DAYS THEREAFTER, NOTIFY THIS OFFICE IN WRITING OF ANY CHANGE
                         IN ANY FACT REQUIRED BY THIS APPLICATION.


                                                     ACKNOWLEDGEMENT
The undersigned agree to conduct Bingo Games in strict accordance with the provisions of Section 326.5 of the Penal Code
and the City’s Ordinance relating to the Conduct of Bingo Games, as they may be amended from time to time, and agree that
the license to conduct Bingo Games may be revoked upon violation of any such provisions.


The undersigned agree that the Applicant is an eligible organization as described by Revenue and Taxation Code Sections
23702 (a), (b), (d), (e), (f), (g), and (i) and that applicant is eligible to apply for license and conduct Bingo Games in the City of
Lancaster under provisions of Section 326.5 of the Penal Code, and as provided in the City’s Ordinance relating to the conduct
of Bingo Games.


We certify under penalty of perjury that the information contained herein is true and correct. As a condition for the issuance
of the license applied for, we agree to submit any additional information that may be required to conduct all phases of this
business in accordance with regulations established for such business, and to maintain all trucks or equipment that may be
used in connection therewith in conformance with all applicable laws, ordinances and regulations.


                                      Signatures of two presiding officers required.


SIGNATURE                                            TITLE                                        DATE

PRINT NAME                                                         PHONE # (      )      -


SIGNATURE                                            TITLE                                        DATE

PRINT NAME                                                         PHONE # (      )      -

				
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