Nebraska Application for Gaming Manager
Nebraska Application for Gaming Manager FORM • Include license fee of $100 • Incomplete applications will be returned 50C PLEASE DO NOT WRITE IN THIS SPACE 1 Licensed Organization’s Name 2 Nebraska Identiﬁcation Number of Licensed Organization 3 Type of Application New Renewal Report Changes Cancel (Return license) GAMING MANAGER INFORMATION (Attach additional sheet if necessary) Social Security Number Name Street Address Date of Birth P.O. Box City State Zip Code County • Your social security number and date of birth are required under the Nebraska Bingo Act, and will be used to request criminal history information from law enforcement agencies to determine if the legal requirements for a gaming manager’s license are met. 4 Are you currently a bingo chairperson or alternate bingo chairperson, as indicated on the Nebraska Schedule I – Bingo License, Form 50, submitted by any licensed organization? NO YES If Yes, indicate the licensed organization’s name and Nebraska Identiﬁcation Number: Licensed Organization’s Name Nebraska Identiﬁcation Number 5 Do you hold or have you previously held any other licenses issued under the Nebraska Bingo Act, the Nebraska Pickle Card Lottery Act, the Nebraska Lottery and Rafﬂe Act, or the Nebraska County and City Lottery Act? NO YES If Yes, indicate the types of licenses and their current status (active, suspended, canceled, revoked, expired): 6 Do you or your spouse have any interest, directly or indirectly, in any business licensed as a commercial lessor of bingo premises or as a manufacturer or distributor of bingo equipment and/or pickle card units in Nebraska? NO YES If Yes, provide detailed explanation: 7a Have you been convicted of, forfeited bond upon a charge of, or pled guilty or nolo contendere to any FELONY OR MISDEMEANOR AT ANY TIME involving fraud, theft, any gambling activity, willful failure to make required payments or reports, or ﬁling false reports with a governmental agency at any level? This INCLUDES shoplifting or issuing bad checks. NO YES 7b Have you been convicted of, forfeited bond upon a charge of, or pled guilty or nolo contendere to any felony other than those listed in 7a within the last 10 years? NO YES If you answered Yes to 7a or 7b, indicate the date and place the incident occurred, the court case or docket number under which it is ﬁled, the original charge or ultimate disposition of the matter, and a description of the events which are the subject of the incident. 8 Have you ever been ﬁngerprinted for a license under the Nebraska Bingo Act, the Nebraska Pickle Card Lottery Act, or the Nebraska County and City Lottery Act? NO YES If Yes, indicate the approximate date you were ﬁngerprinted and the type of license involved. Date: Type of License: 9 Have you ever been ﬁngerprinted by the Nebraska Liquor Control Commission in conjunction with an application for a liquor license? NO YES If Yes, indicate the approximate date you were ﬁngerprinted and the number of the liquor license. Date: Liquor License Number: If you answered No to lines 8 and 9, see the instructions for lines 8 and 9 on the reverse side of this application. 10 Bingo Location (Street address, city, state, zip code, county) 11 Type of Compensation Salary $ per Other, explain Volunteer, no compensation Under penalties of law, I declare that I have examined this application, and to the best of my knowledge and belief, it is correct and complete. I will comply with all of the provisions of the Nebraska Bingo Act, the Nebraska Pickle Card Lottery Act, the Nebraska Lottery and Rafﬂe Act, the sign Nebraska Small Lottery and Rafﬂe Act, and the regulations adopted under such Acts. here ( ) Signature of Applicant Date Daytime Telephone Number • LICENSED ORGANIZATION AUTHORIZATION — Signature of Utilization of Funds Member I declare that I have examined this application and approve the person to act as a gaming manager on behalf of the above-named licensed sign organization. here ( ) Signature of Utilization of Funds Member Date Daytime Telephone Number Mail the original application and $100 fee to: NEBRASKA DEPARTMENT OF REVENUE, CHARITABLE GAMING DIVISION, P.O. BOX 94855, LINCOLN, NE 68509-4855 Visit our Web site: www.revenue.ne.gov/gaming 9-186-2001 Rev. 5-2008 PLEASE MAKE A COPY FOR YOUR RECORDS. Supersedes 9-186-2001 Rev. 6-2007 INSTRUCTIONS WHO MUST FILE. Any nonprofit organization or Charitable Gaming Division, P.O. Box 94855, Lincoln, volunteer fire company or volunteer first-aid, rescue, Nebraska 68509-4855. Please make a copy of this ambulance, or emergency squad applying for a Class II application for your records. license to conduct bingo must license an individual as An individual must have physical possession of the a gaming manager. The gaming manager is responsible license issued by the Department before he or she may for the supervision and operation of the bingo game on work at a bingo occasion as a gaming manager. behalf of the licensed organization and the conduct of all other gaming activities permitted by law at a bingo game, SPECIFIC INSTRUCTIONS including lottery by the sale of pickle cards, lotteries, and LINE 4. Each organization licensed to conduct bingo rafﬂes. The Nebraska Application for Gaming Manager, must designate a member of its organization as a Form 50C, must be ﬁled by any individual wishing to bingo chairperson. A licensed organization may also function as a gaming manager for a licensed organization. designate up to three alternate bingo chairpersons. If a An individual may be licensed as a gaming manager licensed organization has designated you as its bingo for more than one licensed organization. A separate chairperson or alternate bingo chairperson, provide that Nebraska Application for Gaming Manager, Form 50C, organization’s name and Nebraska identiﬁcation number. and $100 license fee must be submitted for each licensed That organization must replace you as a bingo chairperson organization. or alternate bingo chairperson before you can be issued a An individual licensed as a gaming manager may gaming manager’s license. No person designated as a not be connected with, interested in, or otherwise bingo chairperson or alternate bingo chairperson may concerned directly or indirectly with any party licensed hold a license as a gaming manager. as a manufacturer, distributor, or commercial lessor. An LINE 5. Identify any licenses you currently hold or have individual licensed as a gaming manager may not be a previously held which were issued under the Nebraska bingo chairperson or alternate bingo chairperson nor hold Bingo Act, the Nebraska Pickle Card Lottery Act, the any other type of license(s) issued under the Nebraska Nebraska Lottery and Rafﬂe Act, or the Nebraska County Bingo Act, the Nebraska Lottery and Rafﬂe Act, and the and City Lottery Act. Include the status of such licenses Nebraska Pickle Card Lottery Act. (active, suspended, cancelled, revoked, or expired). WHEN AND WHERE TO FILE. A gaming manager LINE 6. Provide a complete explanation of any interest license issued to an individual for a nonproﬁt organization which you or your spouse may have in any business holding a certiﬁcate of exemption under section 501(c)(3) licensed as a commercial lessor of bingo premises or as or (c)(4) of the Internal Revenue Code expires on a manufacturer or distributor of bingo equipment and/or September 30 of each odd-numbered year and may be pickle card units in Nebraska. renewed biennially. A gaming manager license issued to an individual for a nonproﬁt organization holding a certiﬁcate For purposes of line 6, interest would include, but not of exemption under section 501(c)(5), (c)(8), (c)(10), or be limited to, ownership of any type which you or your (c)(19) of the Internal Revenue Code or any volunteer spouse have in a sole proprietorship, limited liability ﬁre company or volunteer ﬁrst-aid, rescue, ambulance, company, partnership, or corporation licensed as a or emergency squad expires on September 30 of each distributor, manufacturer, or commercial lessor. even-numbered year and may be renewed biennially. LINES 8 AND 9. If you answered “No” to lines 8 All applications for license renewal must be submitted and 9, two ﬁngerprint cards and the proper fees must with the nonproﬁt organization’s bingo license renewal be submitted to the Nebraska State Patrol for criminal application at least 45 days prior to the expiration date of background investigation purposes. To obtain ﬁngerprint the license. An individual who has not been previously cards and instructions for their completion, contact the licensed as a gaming manager may submit the application Charitable Gaming Division at the address or telephone at any time during the licensing period. License fees are number listed below. due in full for the biennial licensing period. However, if a LICENSED ORGANIZATION AUTHORIZATION. new license application is received by the Department and The application for the gaming manager’s license must the license will become effective on or after October 1 be signed by a utilization of funds member of the licensed of the second year of the biennial licensing period, the organization for which you will function as a gaming license fee to be remitted to the Department is one-half manager. The signature of the utilization of funds member of the biennial fee. Checks written to the Department of is necessary to establish that the licensed organization Revenue may be presented electronically. approves you to function as a gaming manager at its bingo The application may also be used during the licensing occasions. period to report changes in the application information Any questions regarding the completion of the Nebraska originally submitted or to cancel the license. If requesting Application for Gaming Manager, Form 50C, should cancellation of the license, please include the original be addressed to the Nebraska Department of Revenue, license certiﬁcate issued by the Department. Charitable Gaming Division, P.O. Box 94855, Lincoln, The application and the required license fee are to Nebraska 68509-4855, telephone (402) 471-5937 or toll be mailed to the Nebraska Department of Revenue, free (877) 564-1315.