Application for a Bingo License
Application No: BA

Name of municipality: Bernards Township

Identification No:  (REQUIRED)

Part A - General

FEE: $20 PER OCCURRENCE

1. Name of applying organization:    (REQUIRED)

2 a. Street address of headquarters: (REQUIRED)
    Address:
    City: State: ZIP:

   b. Mailing address (if different):
    

3. List date(s) and hours for games:
Date (i.e., 05/01/2019)
Hours
(i.e., 8:00AM to 4:00PM)
Date (i.e., 05/01/2019)
Hours
(i.e., 8:00AM to 4:00PM)

4. Address of place where bingo will be played:(REQUIRED)
    Address:
    City: State: ZIP:

   a. Does the applicant own the premises or regularly occupy them for its general purposes?

     (REQUIRED Yes Or 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

Part C - Schedule of Purposes

1. 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, are: (REQUIRED)



2. If any part of the net proceeds are 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, secure the signature of its president or other executive officer to the following certificate:

"It is hereby certified that
will accept from the licensee any part of the net proceeds of the games listed in this application to be turned over to it."

Date: ____________________                      Signature: ________________________________________


Part D - Schedule of Prizes

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, decribe the article and state the retail value; if prizes are to be donated, indicate that fact and estimate as accurately as possible the information requested below.)

Description of Prize Amount (for cash prizes) or Article
(Additionally, please attach a schedule of the games to be conducted.)
Retail value

Part E - Officers of Applicant
At least one officer must be listed with all fields completed. Enter phone number with area code with no '(' and ')'.
(1) Office *
Name of officer *
Age *
Residence address *
Telephone No. (include area code 123-456-7890) *
Day     Evening  
(2) Office
Name of officer
Age
Residence address
Telephone No. (include area code 123-456-7890)
Day     Evening  
(3) Office
Name of officer
Age
Residence address
Telephone No. (include area code 123-456-7890)
Day     Evening  
(4) Office
Name of officer
Age
Residence address
Telephone No. (include area code 123-456-7890)
Day     Evening  

Part F - Members of Applicant who will be in charge of the games
At least one member in Charge must be listed with all fields completed. Enter phone number with area code with no '(' and ')'.
(1) Name of member in Charge *
Age*
Residence address *
Telephone No. (include area code 123-456-7890) *
Day     Evening  
(2) Name of member in Charge
Age
Residence address
Telephone No. (include area code 123-456-7890)
Day     Evening  
(3) Name of member in Charge
Age
Residence address
Telephone No. (include area code 123-456-7890)
Day     Evening  
(4) Name of member in Charge
Age
Residence address
Telephone No. (include area code 123-456-7890)
Day     Evening  

Part G - Members of Applicant who will assist in conducting the games
Name of member
Residence addresse
Age

Part H - Names of other organizations whose members will assist in conducting the games
Name and address of organization
How related
Identification No.
If more space is needed in any section of this application, insert extra sheets of paper.


Part I - Statement of Applicant and member(s) in charge

State of New Jersey

} ss.
County of Somerset

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 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 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 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.

Sworn and subscribed to before me this
______day of_________________, 20_ ___.
____________________________________
Notary Public (Print name)
____________________________________
Signature of Notary Public

____________________________________________________
Signature of Officer and Title
____________________________________________________
Signature of Member-in-Charge
____________________________________________________
Signature of Member-in-Charge
____________________________________________________
Signature of Member-in-Charge
____________________________________________________
Signature of Member-in-Charge



If more space is needed in any section of this application, insert extra sheets of paper.

Applicant's registration slip from the Legalized Games of Chance Control Commission

must be presented to the Municipal Clerk with this application.

 (REQUIRED)

Email Address: (REQUIRED):