APPLICATION FOR BINGO LICENSE

1. Name of Association: Area Code-Phone:

2. Street Address County State Zip Code

3. Location of Bingo Games (Address, Number, Street)

4. The association is a senior citizen’s group that conducts bingo for its members only [ ] YES [ ] NO

5. The association is an agricultural association or county fair [ ] YES [ ] NO

6. This year the association will conduct bingo during only one period which shall not exceed three 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 (Date-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.

11. The association ( check the appropriate line)

[ ] is the sole owner of the equipment used in playing bingo.

[ ] is joint owner with a licensed association of the 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.

12. The premises on which bingo is played (check appropriate line)

[ ] are owned by the association.

[ ] are not leased from the owner under an oral agreement.

[ ] are 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.

13. The personal property used in the conduct of the game (check appropriate line)

[ ] 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.

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.

15. Bingo games (check appropriate line)

[ ] will not be conducted by the association more than twice in any one week.

[ ] will be conducted at carnivals or expositions not exceeding ten days in duration.

16. The association will not award a total of more than $4,000.00 in prizes in one calendar day.

17. The association is a nonprofit association as defined in the Bingo Law.

__________________________________________________

Signature of Executive Officer or Secretary of the Association

COMMONWEALTH OF PENNSYLVANIA:

SS

COUNTY OF :

________________________

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

INSTRUCTIONS FOR COMPLETION OF FORM

A . All information shall be typed or printed in black or blue ink.

B. Submit the application, upon completion, to the county treasurer, or in any home rule county of city

of the first class, where there is no elected treasurer, to the designee of the governing authority.

C. Associations that conduct bingo during one period each year for not more than three consecutive days

shall pay a $15 annual licensing fee. Recognized senior citizen’s groups who conduct bingo for their

members only shall pay a fee of $50 per year. The license fee for all other non-profit associations,

including agricultural associations and county fairs, is $100 per year.

D. The application shall be signed by the executive officer or secretary of the association.

E. The association must have existed and conducted business in furtherance of its written constitution,

charter, articles of incorporation or express purpose for two 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.