Duck Race Off-Premises 50/50 Off-Premises Cash Off-Premises Merchandise On-Premises 50/50 On-Premises Merchandise Pull Tab-Per Day Pull Tab-Per Year Tricky Tray Wheels

AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY N/A

Yes No

AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY N/A

Yes No

Yes No

The items of expense intended to be incurred or paid in connection with the games listed in this application, the names and addresses of the persons to whom each item is to be paid, and the purpose for which each item is to be paid.

Organization Name

From whom will you rent the premises?

Type of Game

Is there any part of the net proceeds to be devoted to a purpose allowed by the Bingo/Raffles Licensing Law by turning the same over to another organization which is exclusively devoted to such purposes?

State

Is the raffles equipment to be rented?

Total Retail Value

Schedule of Prizes

ZIP

A description of all prizes to be offered and given in all of the games listed in this application is as follows. For cash prizes, state the amount; For merchandise, describe the article and state the retail value; if prizes are to be donated, indicate that fact and estimate as accurately as possible.

Schedule of Expenses

# of Items

The specific purpose(s) to which the entire net proceeds of the games listed in this application are to be devoted, and the manner in which they are to be so devoted:

A license is requested to conduct bingos/raffles of the kind stated on the date, or on each of the dates, and during the hours listed.

Do you own the premises or regularly occupy them for its general purposes?

Address (where game(s) will be played)

ZIP

Game(s) Details

Game(s) Date(s) & Hours Details

City

Type of Raffle

Premises Owner Address

# of Games

Schedule of Purposes

City

State

AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY N/A

Yes No

AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY N/A

State

ZIP

City

Members of Applicant In Charge of the Games

List the names of other organizations whose members will assist in conducting the games:

City

Phone #

Mailing address same as headquarters?

Headquarters Address

State

Members of Applicant Conducting the Games

Officers of Applicant Details

Mailing Address

Email

List the members of applicant who will be in charge of the games:

Organization Details

ZIP

List the members of applicant who will assist in conducting the games:

Name

Other Organizations Details

Amendment Details

Amendments

Attachments

Amount Due

Fee Schedule

Please attach the below documents and any other supporting documents:

• Copy of Legalized Games of Chance License.
• Applicant's registration slips from the Legalized Games of Chance Control Commission.
• If any part of the net proceeds is to be devoted to a purpose allowed by the Bingo Licensing Law by turning the same over to another organization which is exclusively devoted to such purposes, attach a certificate with the signature of its president or other executive officer.
• If the premises is to be rented, attach form 10, "Statement of Landlord".
• For Raffles, if raffles equipment is to be rented, attach a statement by the raffle's equipment lessor.

For Bingo Applications ONLY:

• Copy of Declaration of Trust. (LGCCC Form 21)
• Copy of Hall Rental Request Form.
• Copy of Hold Harmless Agreement & Insurance Certificate Application.
• Renters Agreement from the Owner. (On Company Letter Head)
• Statement of Landlord. (LGCCC Form 10-A)

For Pocketbook Bingo:

• Schedule of Games.

Certification

Applicant Signature

We do hereby each make the following statement, under oath, with respect to the foregoing application:

1. The applicant (is) (is not) limited in its activities to the furtherance of one or more authorized purposes as defined in the Bingo/Raffles Licensing Law.
2. Prior to the issuance of any license to it to conduct games of chance, the applicant was actively engaged in serving one or more “authorized purposes.”
3. The applicant has received and used, and in good faith expects to continue to receive and use, to further one or more authorized purposes, funds from sources other than games of chance.
4. The conduct of the games on the occasion or occasions for which this application is made will be to raise and devote the entire net proceeds to the authorized purpose described in the application.
5. For each occasion for which a license is sought, one or more of the members listed who are familiar with the Bingo/Raffles Licensing Law and the Rules and Regulations, will be in full charge of, and primarily responsible for, the conduct of the games.
6. No commission, salary, compensation, reward or recompense will be paid to any person for holding, operating or conducting or assisting in the holding, operation or conducting, of the games, except to bookkeepers or accountants for professional services not exceeding the amounts fixed by the Schedule of Fees, as well as the compensation for the Licensed Compensated Workers pursuant to N.J.A.C. 13:47-6A. All prizes offered for games conducted on a single occasion will not exceed the limit on the sum or retail value of prizes as provided by the Bingo/Raffles Licensing Law (N.J.S.A. 5:8-25 et seq.) and N.J.A.C. 13:47-6.16 and 13:47-7.2.
7. All statements in the foregoing application are true.