Form SFN53838 "State Gaming License Reapplication Form" - North Dakota

What Is Form SFN53838?

This is a legal form that was released by the North Dakota Attorney General's Office - a government authority operating within North Dakota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2017;
  • The latest edition provided by the North Dakota Attorney General's Office;
  • 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 fillable version of Form SFN53838 by clicking the link below or browse more documents and templates provided by the North Dakota Attorney General's Office.

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Download Form SFN53838 "State Gaming License Reapplication Form" - North Dakota

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License Number: (Office Use)
STATE GAMING LICENSE
G -
REAPPLICATION FORM
License Year Ending:
June 30,
OFFICE OF ATTORNEY GENERAL
SFN 53838 (Rev. 10-2017)
1. Official, Legal Name of Organization: (Do Not Abbreviate)
Business Telephone Number:
Business Address: (Street)
City:
State:
Zip Code:
Mailing Address:
City:
State:
Zip Code:
Address where gaming accounting records are kept:
City:
Zip Code:
State:
E-mail Address:
Contact Person:
Official Position of Contact Person:
2. Is organization recognized as tax exempt by the Internal Revenue Service?
3. Provide organization's Federal Employer Identification Number (EIN):
YES
NO
4. Name and Title of Organization's Top Executive Official: (i.e., Cmdr., Pres., etc.)
Daytime Telephone Number:
5. Name of Gaming Manager:
Daytime Telephone Number:
6. Signature of Gaming Manager:
Date:
7. List the Full Governing Board of the Organization - The full governing board is primarily responsible and may be held accountable for the proper
determination and use of net proceeds.
Name:
Telephone Number:
Name:
Telephone Number:
Name:
Telephone Number:
Name:
Telephone Number:
Name:
Telephone Number:
Name:
Telephone Number:
Name:
Telephone Number:
Name:
Telephone Number:
Name:
Telephone Number:
Name:
Telephone Number:
Telephone Number:
Name:
Telephone Number:
Name:
8. Does the Organization Own or Rent the Premises at Which the Games of Chance will be Conducted?
Own
Rent
AFFIDAVIT:
The Top Executive Official declares that the information is correct and
Signature of Top Executive Official:
Date:
authorizes the Attorney General to inspect the organization's bank and
accounting records.
License Number: (Office Use)
STATE GAMING LICENSE
G -
REAPPLICATION FORM
License Year Ending:
June 30,
OFFICE OF ATTORNEY GENERAL
SFN 53838 (Rev. 10-2017)
1. Official, Legal Name of Organization: (Do Not Abbreviate)
Business Telephone Number:
Business Address: (Street)
City:
State:
Zip Code:
Mailing Address:
City:
State:
Zip Code:
Address where gaming accounting records are kept:
City:
Zip Code:
State:
E-mail Address:
Contact Person:
Official Position of Contact Person:
2. Is organization recognized as tax exempt by the Internal Revenue Service?
3. Provide organization's Federal Employer Identification Number (EIN):
YES
NO
4. Name and Title of Organization's Top Executive Official: (i.e., Cmdr., Pres., etc.)
Daytime Telephone Number:
5. Name of Gaming Manager:
Daytime Telephone Number:
6. Signature of Gaming Manager:
Date:
7. List the Full Governing Board of the Organization - The full governing board is primarily responsible and may be held accountable for the proper
determination and use of net proceeds.
Name:
Telephone Number:
Name:
Telephone Number:
Name:
Telephone Number:
Name:
Telephone Number:
Name:
Telephone Number:
Name:
Telephone Number:
Name:
Telephone Number:
Name:
Telephone Number:
Name:
Telephone Number:
Name:
Telephone Number:
Telephone Number:
Name:
Telephone Number:
Name:
8. Does the Organization Own or Rent the Premises at Which the Games of Chance will be Conducted?
Own
Rent
AFFIDAVIT:
The Top Executive Official declares that the information is correct and
Signature of Top Executive Official:
Date:
authorizes the Attorney General to inspect the organization's bank and
accounting records.
Office of Attorney General
SFN 53838 (Rev. 02-2017)
Cities or Counties (if site is outside limits of an incorporated city) in which games of chance will be conducted:
City
County
(provide only if renewing a county license)
(If additional space is needed, attach separate sheet.)
Total number of licenses organization is applying for (add each city or county listed above):
$150.00
x
Total fee.
Enclose total license fee with this application.
(Check payable to: ND Attorney General)
Office of Attorney General
RETURN TO:
Licensing Section
600 E Boulevard Ave Dept. 125
Bismarck, ND 58505-0040
Telephone: 701-328-2329 OR
1-800-326-9240
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