HomeMy WebLinkAboutApplication for Bingo LicenseApplication for
Bingo License
Phone Number
2. Association Address
3. Location of Bingo
Games (Address)
4. The association is a senior citizen's group which conducts bingo for its member only?Yes No
5. The association is an agricultural association or county fair?Yes No
6. This year the association will conduct bingo during one period which shall not exceed three (3) consecutive days?
Yes No
7. The membership of the association consists exclusively of elderly residents of a senior citizen housing project?Yes No
8. The association was formed :
Month Year
9. The association will not permit any person under the age of 18 to play bingo unless accompanied by an adult
10. The facility where the game of bingo will be played has adequate entrances and exits and adequate sanitary facilities
is the sole owner of the equipment used in playing bingo
is joint owner with a licensed association of equipment used in playing bingo
leases the equipment from another licensed 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 the bingo games
is contracting with a charitable organization or outside operator to conduct bingo at expositions, carnivals or fairs
11. The association (select the appropriate line below)
12. The premises on which bingo is played (select the appropriate line below)
13. The personal property used in the conduct of the game (select the appropriate line below)
is owned by the association
is not leased from the owner under an oral agreement
is not leased from the owner under a written agreement providing for the rental price to be determined by the receipts
realized from the bingo games or the number of people attending the bingo games.
is owned by the association
is not leased from the owner under an oral agreement
is not leased from the owner under a written agreement providing for the rental price to be determined by the receipts
realized from the bingo games or the number of people attending the bingo games.
1. Association Name
County of Franklin, PA
Melody Shuman, Treasurer
14. 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
Bingo games (please check the appropriate line)
The association will not award a total of more the $4,000.00 in prizes in one (1) calendar day
The association is a nonprofit association as defined in the Bingo Law
Applicant states that the above referenced association for which the application is made is an "association" as defined in Section 3 of
the Pennsylvania Bingo Law, which is a volunteer fire company or auxiliary thereof, ambulance association or a religious, charitable,
fraternal, veterans, civic, county fair, or agricultural association organized as a nonprofit organization which shall have existed, and
conducted business in furtherance of their written constitution charter, articles of incorporation or bylaw express purpose, for two
years prior to application for this license.
Signature of Executive Officer or Secretary of the Association
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF FRANKLIN: SS
Before me this day personally appeared ______________________________________ who being duly sworn according to law,
deposes and says that the statements contained in the foregoing application are true and correct.
Subscribed and sworn to before me this ______________ day of ____________________, 20___
My commission expires on: _________________________
____________________________________
Notary Signature
will not be conducted by the association more than twice in any one (1) week
will be conducted at carnivals or expositions not exceeding ten (10) days in duration
INSTRUCTIONS FOR COMPLETION OF FORM
A. All information shall be typed or printed in black or blue ink ALL APPLICATIONS MUST BE SIGNED AND NOTARIZED.
B. The application shall be signed by the executive officer or secretary of the association. Mail the notarized, signed application upon
completion to:
Franklin County Treasurer
272 N. Second Street
Chambersburg, PA 17201
C. Associations which conduct bingo during one period each year for not more than three consecutive days shall pay a $15.00
annual licensing fee. Recognized senior citizens' groups who conduct bingo for their members only shall pay a fee of $50.00 per year.
The license fee for all other non-profit associations, including agricultural associations and county fairs is $100.00 per year.
D. All first time applicants for the Regular $100.00, Regular $50.00 Senior Citizen, and $15.00 Limited License must provide the
following documentation:
1. Charter or Articles of Incorporation proving non-profit status and two (2) year eligibility
2. A copy of a lease if you are renting the game site
3. A copy of a lease if you are renting the equipment from another non-profit that has a valid Bingo License
E. The association must have existed on conducted business in the furtherance of its written Constitution, Charter, Articles of
Incorporation or express purposes for two (2) years prior to applying for a license.
EXCEPTION: An association whose membership consists exclusively of elderly residents of a senior citizen housing project may apply
for a license immediately after it is organized.
Make checks payable to Melody Shuman , Treasurer