Form CG-4 "Facility License Application" - Kentucky

What Is Form CG-4?

This is a legal form that was released by the Kentucky Department of Charitable Gaming - a government authority operating within Kentucky. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2018;
  • The latest edition provided by the Kentucky Department of Charitable Gaming;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CG-4 by clicking the link below or browse more documents and templates provided by the Kentucky Department of Charitable Gaming.

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Download Form CG-4 "Facility License Application" - Kentucky

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For office use only:
Commonwealth of Kentucky
 Fee paid
Form CG-4
Public Protection Cabinet
2018
DEPARTMENT OF CHARITABLE GAMING
FACILITY LICENSE APPLICATION
A COMPLETE APPLICATION MUST BE RECEIVED AT LEAST 60 DAYS
PRIOR TO THE INTENDED START OF YOUR LICENSE OR THE EXPIRATION
OF YOUR CURRENT LICENSE.
GENERAL FACILITY INFORMATION
1.
Name of applicant:


New
Renewal FAC-
2.
Is applicant organized as:
Corporation
Partnership
Limited Liability Co. (LLC)
Sole Proprietorship
Other
3.
If "other", explain in detail:
Applicant’s federal employer tax identification number:
4.
5.
Name of facility, if different from name of applicant:
6a.
Mailing address of applicant (P.O. Box not acceptable):
City:
State/Zip Code:
County:
Telephone:
6b.
Street address of facility:
City:
State/Zip Code:
County:
Telephone:
Email address:
Website address:
6c.
County in which facility is located:
6d.
Description of gaming facility.
a.
Square footage of gaming facility:
b.
Capacity level of gaming facility:
c.
Available parking area for gaming facility (estimate number of parking
spaces or size of parking area):
d.
Certificate of Occupancy date:
Page 1 of 7
For office use only:
Commonwealth of Kentucky
 Fee paid
Form CG-4
Public Protection Cabinet
2018
DEPARTMENT OF CHARITABLE GAMING
FACILITY LICENSE APPLICATION
A COMPLETE APPLICATION MUST BE RECEIVED AT LEAST 60 DAYS
PRIOR TO THE INTENDED START OF YOUR LICENSE OR THE EXPIRATION
OF YOUR CURRENT LICENSE.
GENERAL FACILITY INFORMATION
1.
Name of applicant:


New
Renewal FAC-
2.
Is applicant organized as:
Corporation
Partnership
Limited Liability Co. (LLC)
Sole Proprietorship
Other
3.
If "other", explain in detail:
Applicant’s federal employer tax identification number:
4.
5.
Name of facility, if different from name of applicant:
6a.
Mailing address of applicant (P.O. Box not acceptable):
City:
State/Zip Code:
County:
Telephone:
6b.
Street address of facility:
City:
State/Zip Code:
County:
Telephone:
Email address:
Website address:
6c.
County in which facility is located:
6d.
Description of gaming facility.
a.
Square footage of gaming facility:
b.
Capacity level of gaming facility:
c.
Available parking area for gaming facility (estimate number of parking
spaces or size of parking area):
d.
Certificate of Occupancy date:
Page 1 of 7
Note: All premises or facilities on which or in which charitable gaming is conducted shall meet
all applicable federal, state, and local code requirements relating to life, safety, and health.
OFFICER INFORMATION
7a.
Please give the following information for the chief executive officer and the chief financial officer of the
applicant. Note: These officers shall be subject to a state and FBI criminal history background check and
fingerprinting will be required. Additional information relating to the procedures for the background checks
will be forwarded to applicant.
Chief Executive Officer:
Chief Financial Officer:
Name:
Name:
Date of birth:
Date of birth:
Social Security number:
Social Security number:
Note: PO Box is not acceptable
Note: PO Box is not acceptable
Home street address:
Home street address:
City:
City:
State/Zip:
State/Zip:
County:
County:
Home telephone: (
)
Home telephone: (
)
Work telephone: (
)
Work telephone: (
)
Email address:
Email address:
7b.
The following information is required for officers of the applicant not listed in question #7a above:
Officer's title:
Officer's title:
Name:
Name:
Date of birth:
Date of birth:
Social Security number:
Social Security number:
Note: PO Box is not acceptable
Note: PO Box is not acceptable
Home street address:
Home street address:
City:
City:
State/Zip:
State/Zip:
County:
County:
Home telephone: (
)
Home telephone: (
)
Work telephone: (
)
Work telephone: (
)
Email address:
Email address:
Officer's title:
Officer's title:
Name:
Name:
Date of birth:
Date of birth:
Social Security number:
Social Security number:
Note: PO Box is not acceptable
Note: PO Box is not acceptable
Home street address:
Home street address:
City:
City:
State/Zip:
State/Zip:
County:
County:
Home telephone: (
)
Home telephone: (
)
Work telephone: (
)
Work telephone: (
)
Email address:
Email address:
(Attach additional pages if necessary)
Page 2 of 7
FINANCIAL INTEREST
8.
The following information is required for each individual who has a 10% or greater financial interest in the
applicant (facility). Note: These individuals shall be subject to a state and FBI criminal history background
check, and fingerprinting will be required. Additional information will be forwarded to you relating to the
procedures for the background checks.
Name:
Name:
Date of birth:
Date of birth:
Social Security number:
Social Security number:
Note: PO Box is not acceptable
Note: PO Box is not acceptable
Home street address:
Home street address:
City:
City:
State/Zip:
State/Zip:
County:
County:
Home telephone: (
)
Home telephone: (
)
Work telephone: (
)
Work telephone: (
)
Email address:
Email address:
(Attach additional pages if necessary)
EMPLOYEES AND/OR CONTRACTEES OF THE FACILITY
9.
The following information is required for each employee or contractee of applicant which manages the
facility or provides other authorized services, including security, concessions, janitorial services, etc.:
Business name:
Business name:
Name:
Name:
Date of birth:
Date of birth:
Social Security number:
Social Security number:
Note: PO Box is not acceptable
Note: PO Box is not acceptable
Home street address:
Home street address:
City:
City:
State/Zip:
State/Zip:
County:
County:
Home telephone: (
)
Home telephone: (
)
Work telephone: (
)
Work telephone: (
)
Email address:
Email address:
Mark one:
Mark one:




Employee or
Contractee
Employee or
Contractee
Please provide job title or position held
Please provide job title or position held
and describe regular job duties:
and describe regular job duties:
(Attach additional pages if necessary)
Page 3 of 7
ORGANIZATIONS LEASING FACILITY
10.
The following information is required for each charitable organization to which you currently lease space:
a.
Charitable organization:
License Number:
First gaming day:
Hours of use:
Second gaming day:
Hours of use:
Third gaming day:
Hours of use:
(List all gaming days and hours of use. Attach additional sheet if necessary.)
Rate charged:
Services provided by facility:



gaming space
utilities
insurance



concessions
parking
tables and chairs



adequate storage
security
janitorial service

other non-gaming equipment
Expiration date of current lease:
b.
Charitable organization:
License Number:
First gaming day:
Hours of use:
Second gaming day:
Hours of use:
Third gaming day:
Hours of use:
(List all gaming days and hours of use. Attach additional sheet if necessary.)
Rate charged:
Services provided by facility:



gaming space
utilities
insurance



concessions
parking
tables and chairs



adequate storage
security
janitorial service

other non-gaming equipment
Expiration date of current lease:
(Attach additional pages if necessary)
LEASE AGREEMENTS
11.
Attach a copy of a blank standard lease agreement used between applicant and charitable organization.
12.
Attach copies of each signed lease agreement described in question #10 above.
Please read KRS 238.555(4)and 820 KAR 1:005 to ensure your lease meets the requirements of this statute.
13.
Do you own the facility you are leasing to charitable organizations?


Yes or
No
If “no”, please attach a copy of the lease agreement between applicant and applicant’s lessor and state below
who owns the property where the charitable gaming activities will be conducted.
Name:
Mailing Address:
City/State/Zip:
County:
Telephone:
Page 4 of 7
ADDITIONAL INFORMATION
14.
Is applicant currently licensed or permitted to operate a charitable gaming facility in any other state,
territory, or country?


Yes or
No
If "yes," please list the state(s), territory(ies), or country(ies):
State/territory/country:
State/territory/country:
(Attach additional sheets, if necessary)
15.
Has the applicant had any disciplinary action taken by any other state, territory, or country?


Yes or
No
If "yes", state when, by what regulatory authority, and on what grounds:
16.
Has the applicant ever been denied a license or permit to operate a charitable gaming facility in any
other state, territory, or country?


Yes or
No
If "yes", state when, by what regulatory authority, and on what grounds:
17.
Has the applicant had any disciplinary action taken by any other regulatory authorities in the
Commonwealth of Kentucky?


Yes or
No
If "yes", explain in detail the circumstances:
18.
Has applicant or any individual named in question #7a, 7b or 8 of this application been convicted of a
crime in federal court or the courts of any state, the District of Columbia, or any territory of the United
States?


Yes or
No
If "yes", describe in detail:
19.
Is the applicant or any individual named in question #7a, 7b or 8 of this application under indictment in
federal court or the courts of any state, the District of Columbia, or any territory of the United States?


Yes or
No
If “yes”, describe in detail:
Page 5 of 7
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