"Request to Add a Type Iii Instant Bingo Retail Establishment Location - 501(C)(3) Organizations" - Ohio

"Request to Add a Type Iii Instant Bingo Retail Establishment Location - 501(C)(3) Organizations" - Ohio Download Pdf
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Request to Add a Type Iii Instant Bingo Retail Establishment Location - 501(C)(3) Organizations is a legal document that was released by the Ohio Attorney General - a government authority operating within Ohio.

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Download "Request to Add a Type Iii Instant Bingo Retail Establishment Location - 501(C)(3) Organizations" - Ohio

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Charitable Law Section
Office 800-282-0515
Fax 855-669-2154
rd
150 E Gay St, 23
Floor
Columbus, OH 43215
www.OhioAttorneyGeneral.gov
REQUEST TO ADD A TYPE III INSTANT BINGO RETAIL ESTABLISHMENT LOCATION
501(c)(3) Organizations (ONLY)
A separate copy of this Attachment must be completed for EACH location at which the Applicant intends to conduct
Instant Bingo other than at a Traditional Bingo Session. PLEASE NOTE – If the Applicant has received a Charitable
Bingo License for the current year, requesting additional locations requires an Amendment Fee of $250.
Name of Applicant/Charitable Organization: _________________________________________
1. Provide the day(s) of the week and hours that Instant Bingo will be conducted at the Location.
Sunday
Hours:
.m. to
.m.
Hours:
.m. to
.m.
Monday
Hours:
.m. to
.m.
Hours:
.m. to
.m.
Tuesday
Hours:
.m. to
.m.
Hours:
.m. to
.m.
Wednesday
Hours:
.m. to
.m.
Hours:
.m. to
.m.
Thursday
Hours:
.m. to
.m.
Hours:
.m. to
.m.
Friday
Hours:
.m. to
.m.
Hours:
.m. to
.m.
Saturday
Hours:
.m. to
.m.
Hours:
.m. to
.m.
2. Provide the address of the Premises where Instant Bingo will be conducted by or on behalf of the Applicant:
Street Address
City, State, Zip Code
County
Telephone Number
Business Name and any dba’s for the Premises where Instant Bingo will be conducted on behalf of the Applicant
* The Premises listed must be in the same County as Applicant’s principal place of business.
3. Is a liquor permit issued for any part of the Premises where Applicant will conduct Instant Bingo?
Yes
No
If yes, provide the permit number:
Charitable Law Section
Office 800-282-0515
Fax 855-669-2154
rd
150 E Gay St, 23
Floor
Columbus, OH 43215
www.OhioAttorneyGeneral.gov
REQUEST TO ADD A TYPE III INSTANT BINGO RETAIL ESTABLISHMENT LOCATION
501(c)(3) Organizations (ONLY)
A separate copy of this Attachment must be completed for EACH location at which the Applicant intends to conduct
Instant Bingo other than at a Traditional Bingo Session. PLEASE NOTE – If the Applicant has received a Charitable
Bingo License for the current year, requesting additional locations requires an Amendment Fee of $250.
Name of Applicant/Charitable Organization: _________________________________________
1. Provide the day(s) of the week and hours that Instant Bingo will be conducted at the Location.
Sunday
Hours:
.m. to
.m.
Hours:
.m. to
.m.
Monday
Hours:
.m. to
.m.
Hours:
.m. to
.m.
Tuesday
Hours:
.m. to
.m.
Hours:
.m. to
.m.
Wednesday
Hours:
.m. to
.m.
Hours:
.m. to
.m.
Thursday
Hours:
.m. to
.m.
Hours:
.m. to
.m.
Friday
Hours:
.m. to
.m.
Hours:
.m. to
.m.
Saturday
Hours:
.m. to
.m.
Hours:
.m. to
.m.
2. Provide the address of the Premises where Instant Bingo will be conducted by or on behalf of the Applicant:
Street Address
City, State, Zip Code
County
Telephone Number
Business Name and any dba’s for the Premises where Instant Bingo will be conducted on behalf of the Applicant
* The Premises listed must be in the same County as Applicant’s principal place of business.
3. Is a liquor permit issued for any part of the Premises where Applicant will conduct Instant Bingo?
Yes
No
If yes, provide the permit number:
4. Are the Premises used by more than one organization for the purpose of conducting Instant Bingo?
Yes
No
If yes, provide the name(s) of the other organization(s):
5. Will the equipment used to conduct bingo be owned or leased by the Applicant?
Owned
Leased
If the equipment will be leased, list the name of the lessor and the rental amount.
Legal Name
Equipment Rental Amount
6. Custodian of Bingo Records: Identify the person who will be responsible for maintaining and having custody of
the complete bingo records for this location as required by Ohio Revised Code Section 2915.10:
First/Last Name
Title
Home Address (Street
Phone Number
Date of Birth
Address, City, State Zip)
7. Primary Bingo Game Operator: In the table below, identify the person or persons who will have overall
supervision and management of bingo at this location (primary bingo game operator.) The primary bingo game
operator (s) will be responsible for holding, operating, and conducting these bingo activities in accordance with the
license and the provisions of Ohio Revised Code Sections 2915.01 et seq. At least one person must assume these
responsibilities:
First/Last Name
Title
Home Address (Street
Phone Number
Date of Birth
Address, City, State Zip)
Updated: 6/28//2018
2 of 4
8. Bingo Volunteers: In the table below, identify each and every person who will assist or work in the operation of
instant bingo at this location. Please use additional sheets if necessary:
First/Last Name
Title
Home Address (Street
Phone Number
Date of Birth
Address, City, State Zip)
Updated: 6/28//2018
3 of 4
Acknowledgement Clause
State of Ohio
:
: SS.
County of ____________________
:
Print or Type the Name of Applicant/Charitable Organization
By signing this application I affirm or swear as follows:
I am the principal person of Applicant/Organization responsible for submitting this Application and all applicable
Attachments.
I am the person who has the overall responsibility for the operation and control of the organization or I am the highest
elected official in this organization.
I am familiar with and have actual knowledge of the facts underlying this Application and I know that Applicant has
been in continuous existence as a charitable organization as required by Ohio Revised Code Section 2915.01(H).
I am fully authorized to submit this Application on behalf of Applicant identified herein; and to the best of my
knowledge, information and belief, the statements made in this Application and its Attachments are true and accurate.
Further, these documents are originals or true and accurate copies of the originals.
I understand that making of false statements in this Application constitutes grounds for denying this application for a
bingo license.
I acknowledge that I am aware that Ohio Revised Code Section 2921.13(A) entitled Falsification provides that
no person shall knowingly make a false statement, or knowingly swear or affirm the truth of a false statement
previously made when the statement is made for the purpose of securing the issuance of a license, permit,
authorization, certificate, registration, release, or provider agreement by a governmental agency.
I acknowledge that I am aware that Ohio Revised Code Section 2921.13(E) entitled Penalty provides that whoever
violates R.C. Section 2921.13 is guilty of falsification, a misdemeanor of the first degree.
Signature of Principal Person
Printed Name of Principal Person
Title
Subscribed and sworn to before me this __________ day of ___________________________, 201__ by the above
named person who acknowledged voluntary signature of this Application for a 201__ Charitable Bingo License.
Notary Public
Seal or Notary Stamp
Commission Expiration Date:
Updated: 6/28/2018
4 of 4
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"Request to Add a Type Iii Instant Bingo Retail Establishment Location - 501(C)(3) Organizations" - Ohio Download Pdf
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