Temporary Bingo Form – Fill Out and Use This PDF

Charitable Bingo Operations Division

TAXPAYER INFORMATION

PLEASE PRINT LEGIBLY OR TYPE

BINGO OCCASIONS

NOTE: This application must be received at least thirty (30) working days prior to the irst bingo occasion being requested.

ORGANIZATION LOCATION

6.

Name of organization's primary business ofice (If no business ofice, indicate the principle residence of your CEO)

Physical address of your organization's primary business ofice (Use Street Address, NOT PO Box or Rural Route. Do not give directions, i.e., 5 miles north of I-20.)

	City		State		ZIP Code		County
TLC #9515 (Rev. 8/14)							Page 1 of 4

Name of Organization		Taxpayer Number (if issued)

PLAYING LOCATION

Information about the location at which the game will be conducted:

7.

Name of location

Address (Use Street Address, NOT PO Box or Rural Route. Do not give directions, i.e., 5 miles north of I-20.)

	City		State	ZIP Code		County
	Playing Location Phone Number (Area Code & Number)
8.	Is this location inside the city limits of the city named in Item 7?	❏ Y E S		❏ N O
9.	Is this location in the same or adjacant county as the authorized organization's primary business ofice address?				❏ Y E S	❏ N O

❏Lease, including use of facilities free of charge (go to Item 11)

LESSOR INFORMATION

11.

Name of entity from whom you are leasing premises

Lessor's Taxpayer Number

Mailing Address (Street Address, PO Box or Rural Route. Do not give directions, i.e., 5 miles north of I-20.)

City		State		ZIP Code

LICENSE FEE

Payment of the required license fee must be submitted with this application. The fee for a temporary license is twenty-ive dollars ($25) per occasion.

OPERATOR

Enter the name of the active member of the organization who will serve as the operator at the bingo game(s). This individual serves as the supervisor of the bingo operation and is responsible for all bingo activities on behalf of the licensed organization, including iling quarterly reports. This member must sign Item 18.

13.

Name (LAST, FIRST, MIDDLE INITIAL)

Social Security Number

Driver's License Number

State

Home Address (Street Address, PO Box or Rural Route. Do not give directions, i.e., 5 miles north of I-20.))

City

State

ZIP Code

Phone Number (Area Code & Number)

❏ M

❏ F

Race

Gender

Date of Birth (MM, DD, YYYY)

E-mail Address (optional)

TLC #9515

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Name of Organization		Taxpayer Number (if issued)

BINGO CHAIRPERSON

14.Enter the name and all requested information for the oficer or member of your board of directors who will serve as the Bingo Chairperson for your organization. This individual is responsible for overseeing the organization's bingo activities and reporting back to the membership about those activities.

Name (LAST, FIRST, MIDDLE INITIAL)

Social Security Number

Driver's License Number

State

Home Address (Street Address, P.O. Box or Rural Route. Do not give directions, i.e., 5 miles north of I-20.)

City

State

ZIP Code

Phone Number (Area Code & Number)

❏ M

❏ F

Race

Gender

Date of Birth (MM, DD, YYYY)

E-mail Address (optional)

15. Position(s) held by the Bingo Chairperson:

❏ 03 - Director

❏ 04 - Oficer

CERTIFICATION FOR LICENSE TO CONDUCT CHARITABLE BINGO

16. Has a license been held, or is a license currently held by

❏ Y E S

❏ N O

any organization at the playing location named in Item 7?

If "YES," proceed to Item 18

If "NO," proceed to Item 17

17.The following certiicate must be completed by the County Clerk or City Secretary for the county or city in which you are proposing to conduct charitable bingo. If the County Clerk certiies that the proposed playing location is in a county in which bingo is legalized and not inside the boundaries of an incorporated city or town, the City Secretary's certiication is not required.

COUNTY CLERK'S CERTIFICATE

I hereby certify that the conduct of bingo is lawful in the county named below. I further certify that the location of the premises sought to be licensed herein

	❏ (IS) ❏ (IS NOT)	inside the boundaries of an incorporated city or town.
	Location of playing premises:
	Address
	City			State			ZIP Code		County
	Witness my hand and seal of ofice this ________________________________					day of __________________________________ A.D. (Year) _______________ .

X

County Clerk

SEAL

County Clerk of

Name of County

CITY SECRETARY'S CERTIFICATE

(If not an incorporated city, so state)

I hereby certify that the conduct of bingo is lawful at the location of the premises sought to be licensed herein, and that such location is inside the boundaries of the city or town and is not prohibited by local option election.

Location of playing premises:

Address
City			State			ZIP Code		County
Witness my hand and seal of ofice this	________________________________				day of __________________________________ A.D. (Year) _______________ .

X

City Secretary / Clerk

SEAL

City Secretary of

Name of City

TLC #9515

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Name of Organization		Taxpayer Number (if issued)

CERTIFICATION OF RESPONSIBILITY

You are certifying on a State of Texas License Application that the information provided is true and correct.

There is a substantial penalty for a fraudulent application.

18.We, the undersigned, declare that the organization identiied in this application is a bona ide non-proit organization, that we are active members of the organization, that we will be responsible for conducting charitable bingo games and iling all required returns in accordance with the provisions of the Texas Bingo Enabling Act (BEA) and Charitable Bingo Administrative Rules (CBAR), and that all net proceeds derived from charitable bingo games will be used for charitable purposes as deined in the BEA. We further declare that no person named in this application, any oficer or director of the organization or any person who will supervise or work at the bingo occasion has ever been convicted of a felony, gambling offense, criminal fraud, or a crime of moral turpitude for which ten (10) years have not elapsed since the termination of any sentence, parole, mandatory supervision, or probation served for the offense. We further declare that if granted a license to conduct charitable bingo, a member of the organization identiied in this application designated as an operator will be present at and in charge of each and every charitable bingo game played under this license. We further declare that this license will not be sold, rented, transferred, or otherwise assigned to any group or individual. We further declare that we will keep accurate records of all charitable bingo proceeds and expenses subject to audit by the Texas Lottery Commission. We understand that the failure to abide by the provisions of the BEA and CBAR could subject the signers of this application to possible criminal prosecution and the revocation of this license.

We further certify that all statements in this application and any attachments are true and correct to the best of our knowledge and belief. We, the undersigned, declare that as an oficer of the organization and Bingo Chairperson, we have read and will abide by the above statement.

For Fraternal Organizations Only

We further declare our organization will not authorize a person on behalf of our membership, governing body, or oficers to support or oppose a particular candidate for public ofice by making political speeches; passing out cards or other political literature; writing letters; signing or circulating petitions; making campaign contributions; or soliciting votes.

Bingo Chairperson (cannot sign as Operator)

Print Name and Title

Date

Operator

Print Name and Title

Date

TLC #9515

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