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HomeMy WebLinkAboutApplication for Bingo LicenseAPPLICATION FORBINGO LICENSE COMMONWEALTH OF PENNSYLVANIA 1. Qualified associations may use this form to apply for a license to conduct the game of bingo, pursuant to the Bingo Law, 10 P.S. §§ 301—308.1. 2. All information shall be typed or printed in black or blue ink. 3. Submit the completed application to the county treasurer, or in any home rule county or city of the First Class, where there is no elected treasurer, to the designee of the governing authority. (For Philadelphia County, this is the City of Philadelphia Department of Licenses and Inspections.) 4. Community recognized nonprofit organizations applying for a special permit to conduct bingo for entertainment purposes only are exempt from paying any fee; the application and special permit are issued free of charge. 5. Associations which conduct bingo during one period each year for not more than three (3) consecutive days shall pay a $15.00 annual licensing fee. 6. Recognized senior citizens’ groups who conduct bingo for their members only shall pay a fee of $50.00 per year. 7. The fee for all other nonprofit associations, including agricultural associations and county fairs, is $100.00 per year. 8. The application shall be signed by the executive officer or secretary of the association. The application does not require notarization. INSTRUCTIONS FOR COMPLETION OF FORM Name of Association Phone Number Street Address Location of Bingo Games (Address) CityCounty ZipState APPLICATION FORBINGO LICENSE COMMONWEALTH OF PENNSYLVANIA The association (check the appropriate line): is the sole owner of the equipment used in playing bingo; or is joint owner with a licensed association of the equipment used in playing bingo; or leases the equipment from another association under a written agreement for a fee which is not contingent upon the amount of receipts realized from the playing of bingo or the number of people attending bingo games; or is contracting with a charitable organization or outside operator to conduct bingo at expositions, carnivals, or fairs. This year the association will conduct bingo during only one period which shall not exceed three (3) consecutive days Yes No If yes, list start date: _____________________________________________________________________________ The premises on which bingo is played (check appropriate line): are owned by the association; or are leased from the owner under a written agreement. The rental price is not determined by receipts realized from the bingo games or the number of people attending the games. The association is a bona fide consolidated volunteer fire company. Yes No • The association is conducting bingo for entertainment purposes only and all prizes awarded will be of nominal value only. • The association shall not conduct bingo for the purpose of making a profit. • No person who has been convicted of a felony or a violation of the Bingo Law shall be permitted to manage, set up, supervise or participate in the operation of the bingo game. • No person shall be compensated for services rendered in the operation of bingo under this license. The association is a nonprofit community recognized organization applying for a special permit to play entertainment bingo only, subject to the following requirements: Yes No The association is a senior citizens’ group which conducts bingo for its members only. Yes No The association is an agricultural association or county fair. Yes No APPLICATION FORBINGO LICENSE COMMONWEALTH OF PENNSYLVANIA The association is not leasing the premises or personal property used to play the game from a person who has been convicted of a felony or a violation of the Bingo Law. The association will not award prizes with a value that exceeds $500.00 for any one game of bingo, except for jackpot games which shall not exceed $4000.00 for one such game. In addition, no more than $8000.00 in prizes shall be awarded in any calendar day. The association will comply with the provisions of the Bingo Law and other applicable laws and regulations. Date Title Print Name Signature of Officer Preparing Application An advertisement of the association’s bingo games shall contain the date, time, location, whether cash or merchandise prizes will be awarded, and the name of the association licensed to conduct the bingo game and the name of the individual in charge of the operation of the game The association is a nonprofit association as defined in the Bingo Law. The association will not permit any person under the age of 18 to play bingo unless accompanied by an adult. The facility where the game of bingo will be played has adequate entrances and exits and adequate sanitary facilities. The personal property used in the conduct of the game (check appropriate line): is owned by the association; or is leased from the owner under a written agreement. The rental price is not determined by receipts realized from the bingo games or the number of people attending the games. Date the association was formed on: APPLICATION FORBINGO LICENSE COMMONWEALTH OF PENNSYLVANIA Type of Organization Organization has the following documents: *Submit copies of all documents, if possible. Please note the information will be kept on file for at least 2 years, so you will not have to resubmit this information if you have already done so and there are no changes. Volunteer Fire Company Auxiliary Group Ambulance Association Religious Charitable Fraternal Veterans Civic Certificate of Charter Constitution By-Laws Mission Statement Articles of Incorporation Deed/Lease to Licensed Premises IRS (Federal) Exemption Award Letter State Exemption Award Letter Name Date of Birth City, State, Zip Street Address Name Date of Birth City, State, Zip Street Address Name Date of Birth City, State, Zip Street Address Name Date of Birth City, State, Zip Street Address List names, addresses, phone numbers, and dates of birth for all persons that will be permitted by the organization to manage, set up, supervise, or participate in the operation of the bingo. Attach additional sheets as needed. Are all persons listed bona fide members of the association as per Section 303 of the Bingo Law? Yes No APPLICATION FORBINGO LICENSE COMMONWEALTH OF PENNSYLVANIA COMMONWEALTH OF PENNSYLVANIA: COUNTY OF: __________________________________________________________ I declare under penalty of perjury under the law of the Commonwealth of Pennsylvania that the foregoing is true and correct. Signed this: ___________ day of _____________________________, 20 ________. (printed name) (signature) Revised 04/2021 UNSWORN DECLARATION In lieu of notarized affidavit pursuant to Uniform Unsworn Declarations Act (42 Pa.C.S. § 6201 – § 6208).