Application for a Bingo License

Application No. BA
Identification No.
Submit four (4) copies of this application to the Municipal Clerk’s office in the municipality where the games will be conducted.
Please print clearly.
Name of municipality:
Part A - General
1. Name of applying organization:
2a. Street address of headquarters:
b. Mailing address (if different):
3. List date(s) and hours for games:
Date Hours
Date Hours
4. Address of place where bingo will be played:
a. Does the applicant own the premises or regularly occupy them for its general purposes?
Yes No
b. If “No,” from whom will the applicant rent the premises?
Name
Address
c. If premises are to be rented, attach Form 10, “Statement of Landlord.”
Part B - Schedule of Expenses
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, are:
Item of Expense Name and address of supplier Purpose