Form 301 Charitable Gaming Supplier Permit Application - Virginia

Form 301 or the "Charitable Gaming Supplier Permit Application" is a form issued by the Virginia Department of Agriculture and Consumer Services.

The form was last revised in February 26, 2018 and is available for digital filing. Download an up-to-date Form 301 in PDF-format down below or look it up on the Virginia Department of Agriculture and Consumer Services Forms website.

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Mail Completed Application To:
FORM 301
VDACS, Office of Charitable and
CHARITABLE GAMING SUPPLIER
Regulatory Programs,
PERMIT
PO Box 526
APPLICATION
Richmond, Virginia 23218
VIRGINIA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES
OFFICE OF CHARITABLE AND REGULATORY PROGRAMS
PO BOX 526, Richmond VA 23218
Licensing Unit Contact No. (804) 786-1382
www.vdacs.virginia.gov
CHARITABLE GAMING SUPPLIER PERMIT APPLICATION
A.
Use this application when applying for either a new or renewal Charitable Gaming Supplier Permit.
B.
Complete the entire application and all attachments. DO NOT LEAVE ANY BLANKS.
C.
Place "N/A" if item is not applicable. Please type or print all answers.
D.
If needed, attach additional documents or explanation sheets.
E.
Ensure application is dated and signed by the appropriate individual(s).
F.
Enclose a non-refundable $1,000 application fee payable to: Treasurer of Virginia.
G.
Retain a copy of the entire application package for your records.
H.
Mail completed application, applicable fee, and all required attachments (identified by corresponding response number) to: VDACS,
Office of Charitable and Regulatory Programs, PO Box 526, Richmond, Virginia 23218.
I.
Allow 90 days for processing a COMPLETE application. Incomplete applications and/or the omission of applicable attachments may
delay the process.
APPLICANT INFORMATION
1.
Applicant Type:
New
Renewal
OCRP No. (Renewal Only)
Type of Product:
Bingo Paper/Supplies
Electronic Devices
Other (Explain)
Instant Bingo/Pull Tabs
Pull Tab Dispensing Devices
2.
Full Business Name:
Corporate Mailing Address:
City:
State:
Zip:
Telephone:
Fax No.
Federal Employer ID No.
3. Corporation's Physical Address:
City:
State:
Zip:
Telephone:
Contact Person:
Title/Position:
Contact Person's Daytime Contact
Telephone No.:
Fax No.:
STATE AND FEDERAL REGISTRATION INFORMATION
4.
Type of Business
Corporation
Limited Liability Company
Check One
Sole Proprietorship
Partnership
Other (Explain on a separate page)
Yes
No
Attachment
5.
Name of Virginia Registered Agent:
Mailing Address:
City:
State:
Zip:
Telephone:
All domestic corporations, foreign corporations, and limited liability companies must be
registered with the Virginia State Corporation Commission. Attach a current copy of a
certificate of good standing from the Virginia State Corporation Commission.
Yes
No
Attachment
Rev. 02/26/18
Supplier Application
Form 301
Page 1 of 4
Mail Completed Application To:
FORM 301
VDACS, Office of Charitable and
CHARITABLE GAMING SUPPLIER
Regulatory Programs,
PERMIT
PO Box 526
APPLICATION
Richmond, Virginia 23218
VIRGINIA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES
OFFICE OF CHARITABLE AND REGULATORY PROGRAMS
PO BOX 526, Richmond VA 23218
Licensing Unit Contact No. (804) 786-1382
www.vdacs.virginia.gov
CHARITABLE GAMING SUPPLIER PERMIT APPLICATION
A.
Use this application when applying for either a new or renewal Charitable Gaming Supplier Permit.
B.
Complete the entire application and all attachments. DO NOT LEAVE ANY BLANKS.
C.
Place "N/A" if item is not applicable. Please type or print all answers.
D.
If needed, attach additional documents or explanation sheets.
E.
Ensure application is dated and signed by the appropriate individual(s).
F.
Enclose a non-refundable $1,000 application fee payable to: Treasurer of Virginia.
G.
Retain a copy of the entire application package for your records.
H.
Mail completed application, applicable fee, and all required attachments (identified by corresponding response number) to: VDACS,
Office of Charitable and Regulatory Programs, PO Box 526, Richmond, Virginia 23218.
I.
Allow 90 days for processing a COMPLETE application. Incomplete applications and/or the omission of applicable attachments may
delay the process.
APPLICANT INFORMATION
1.
Applicant Type:
New
Renewal
OCRP No. (Renewal Only)
Type of Product:
Bingo Paper/Supplies
Electronic Devices
Other (Explain)
Instant Bingo/Pull Tabs
Pull Tab Dispensing Devices
2.
Full Business Name:
Corporate Mailing Address:
City:
State:
Zip:
Telephone:
Fax No.
Federal Employer ID No.
3. Corporation's Physical Address:
City:
State:
Zip:
Telephone:
Contact Person:
Title/Position:
Contact Person's Daytime Contact
Telephone No.:
Fax No.:
STATE AND FEDERAL REGISTRATION INFORMATION
4.
Type of Business
Corporation
Limited Liability Company
Check One
Sole Proprietorship
Partnership
Other (Explain on a separate page)
Yes
No
Attachment
5.
Name of Virginia Registered Agent:
Mailing Address:
City:
State:
Zip:
Telephone:
All domestic corporations, foreign corporations, and limited liability companies must be
registered with the Virginia State Corporation Commission. Attach a current copy of a
certificate of good standing from the Virginia State Corporation Commission.
Yes
No
Attachment
Rev. 02/26/18
Supplier Application
Form 301
Page 1 of 4
STATE AND FEDERAL REGISTRATION INFORMATION
6.
Is the applicant in compliance with the reporting of and filing of all Virginia monthly, quarterly, and
annual reports mandated by the Virginia Employment Commission and the Virginia Department of
Taxation, and the applicable transmittal of funds? If no, please provide a detailed explanation of any
filing matters and/or delinquencies on a separate page.
Yes
No
7.
Please provide the following State assigned account numbers for each entity provided below. If you do not have an assigned number,
please provide a detailed explanation as to why a State number has not been assigned and the exemption that the applicant operates
under.
VA Employment Commission Account No.
VA Department of Taxation Sales Tax No.
VA Department of Taxation Withholding No.
VA Department of Taxation Corp. ID No.
8.
Does the applicant have a current Letter for Company Registration on file with the U.S. Department of
Justice - Gambling Devices Registration Unit in accordance with the Gambling Devices Act of 1962? If
no, please provide a written explanation as to why the applicant is exempt from this registration
Yes
No
requirement.
BUSINESS INFORMATION
9.
Attach a legible list of all locations where the applicant conducts business, including full name of
the business/subsidiary, contact person, telephone and facsimile number, business and mailing
address, city, state, zip code, and official jurisdiction.
Yes
No
Attachment
Does the applicant have offices, warehouse, or other outlets or facilities in addition to those
identified above where gaming equipment and/or supplies are stored, sold, or manufactured? If
yes, please attach a list in the same manner as required above.
Yes
No
10.
Attach a list of at least three credit references including full business name, address, telephone
number and contact person.
Yes
No
Attachment
11.
Attach a copy of each and every permit and/or authorization for each state or province in which
the applicant provides charitable gaming supplies.
Yes
No
Attachment
12.
If previously permitted in Virginia or in any other state or province, has a permit and/or
authorization ever been suspended, revoked, or subject to an administrative proceeding?
Yes
No
If yes, provide all supporting documentation of the suspension, revocation, or administrative
proceeding, the current status of the subject permit, and any agreement entered into in resolution
of the matter.
13
13.
Attach a list of the complete full names and titles of the persons involved with the charitable
gaming supplier applicant as requested below. Please complete a Personnel Information Form for
each individual designated in this section.
Yes
No
Attachment
a.
Sole Proprietor - Provide information for individual owner.
c.
Limited Liability Company - Provide information for each member.
b.
Partnership - Provide information for each partner.
d.
Corporation - Each officer, director, person, owner, or entity having a
10% or greater interest (debt or equity) in the applicant. If an entity,
provide a list of the individual officers, directors, persons, owners and/or
entities having a 10% or greater interest, and the address and contact
information.
14.
Attach a list of all agents/employees/independent contractors who will, in Virginia, provide supplies
or market products designated in Item No. 1. Include the full name, home and mailing address,
city, state, zip code, telephone number, and email address.
Yes
No
Attachment
15.
Has the applicant, a related business entity, or person identified in Item Nos. 13 and 14 ever been
the subject of an administrative or legal action associated with charitable gaming? If yes, provide
complete details on a separate page.
Yes
No
16
Has the applicant, a related business entity, or person identified in Item Nos. 13 and 14 ever been
indicted, convicted, or arrested for any criminal offense? If yes, provide complete details on a
separate page.
Yes
No
Rev. 02/26/18
Supplier Application
Form 301
Page 2 of 4
BUSINESS INFORMATION
17.
Has the applicant, a related business entity, or person identified in Item Nos. 13 and 14 ever been
involved in a civil action that allegedly constituted a crime(s)? If yes, provide complete details on
a separate page.
Yes
No
18.
Has the applicant, a related business entity, or person identified in Item Nos. 13 and 14 ever been
delinquent on any payment owed to a governmental entity or creditor, or ever been sued for a
debt? If yes, provide complete details on a separate page.
Yes
No
19.
Is the applicant, a related business entity, or person identified in Item Nos. 13 and 14 currently a
known party to any criminal and/or civil complaint or investigation? If yes, provide complete
details on a separate page.
Yes
No
20.
Attach a list of all banks and/or financial institutions utilized by the applicant organization,
including name of bank, account number(s), mailing and street address, city, state, zip code,
contact person, and telephone number.
Yes
No
Attachment
21.
Attach a list of the individual(s) and/or companies who prepare OCRP financial reports including
full name of the person, business name, telephone and facsimile numbers, mailing and street
address, city, state, zip code, and email address.
Yes
No
Attachment
22.
Provide the complete physical address of where the applicant's records of charitable gaming sales
and transactions are stored including full name of contact person, physical and mailing address,
city, state, zip code, telephone number, and email address.
Yes
No
Attachment
PLEASE CONTINUE TO NEXT
PAGE
Rev. 02/26/18
Supplier Application
Form 301
Page 3 of 4
PERSONNEL INFORMATION
11 VAC 15-31-20 of the Supplier Regulations provides that no Charitable Gaming Supplier Permit can be issued prior to a
reasonable investigation conducted by the OCRP. The following information is required to conduct a background investigation.
Individuals designated below hereby authorize the OCRP to investigate all matters related to this application, and hereby waives
any rights or causes of action they may have based upon the disclosure of otherwise confidential information.
This form must be completed for each officer, director, person, owner, or entity having a 10% or greater interest (debt or equity),
and/or each person identified in Item No. 13. Please provide complete information and FULL PROPER NAMES. Do not leave
any blanks. Please make copies of this page for each person identified in Item No. 13 of this Application.
By completing this form and affixing my signature, I hereby state that to the best of my knowledge, information, and belief that
there has been no failure to disclose, and I am aware that later discovery of an omission or misrepresentation made in this
application, or made on any statement, document, or information may be grounds for revocation of the applicant's application or
subject the applicant or personnel to criminal penalties in the Commonwealth of Virginia.
I also agree that I will abide by the Charitable Gaming Statute, Supplier Regulations, and any and all laws and regulations of the
Commonwealth of Virginia.
Full Legal Name:
Title:
First Name
Middle Name
Last Name
Social Security No.
Date of Birth
Physical Home Address:
Street Address - No Post Office Boxes
City
State
Zip Code
Mailing Address, If
Different
Mail Address
City
State
Zip Code
E-Mail Address:
Web Page Address:
%
Percentage of Ownership, If Applicable:
Contact Numbers:
Telephone:
Cell Phone No.:
Facsimile:
Other Number:
Signature
Date
Rev. 02/26/18
Supplier Application
Form 301
Page 4 of 4

Download Form 301 Charitable Gaming Supplier Permit Application - Virginia

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