SUN LAKES ROTARY CLUB_REDACTED.PDF

Arizona Form 833 Application for Bingo License
• Type or print in black ink and complete all information requested on this form. If you do not, your application will be returned. All
information is subject to verification. If you need more space, attach additional sheets.
• All bingo licenses expire one year from the date of Issue. To continue conducting bingo games, you must renew your license prior
to the expiration date.
1 Applicant's Name
iiiiiiiim Falsification of information
Sun Lakes Rotary Club
contained in this application
constitutes a Class 6 felony.
2b City REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
88
3a Administrative Office Location
23910 S. Sunland Ct.
3b City State ZIP Code
Sun Lakes AZ 85248
4a Name of Contact Person
Peter Meade
4c E-mail Address 4c Fax No. 81 PM RCVD
N/A
5 Class B and Class C license applicants only: If applying as a qualified organization, check one box to indicate the type of
organization:
Charitable 0 Social 0 Religious 0 Veterans
0 Fraternal 0 Volunteer Fire Department 0 Homeowners Association o Nonprofit Ambulance Service
6 Class B and Class C license applicants only applying as a qualified organization, provide parent or auxiliary information:
6a Parent Name 6b Auxiliary Name
Rotary International end L At.45 cor ak ,om ('/v 3
Address — Number and Street, Rural Rt., Apt. No. Rt., Apt. No.
7 Class B and Class C license applicants only applying as a qualified organization, provide the date the organization was
established in Arizona:1 i i I
8 Class B and Class C license applicants only applying as a qualified organization, list the current officers of the organization:
8a Name 8b Name
Ed Anderson Billy Crump
Title Title
President President - Elect
Address — Number and Street. Rural Rt., Apt. No. Address — Number and Street, Rural Rt., Apt. No.
City State ZIP Code City State ZIP Code
8c Name 8d Name
David S. Mork DeAnne Rasmussen
Title Title
Treasurer Sargent at Arms
Address — Number and Street, Rural Rt., Apt. No. Address — Number and Street, Rural Rt., Apt. No.
Cit State ZIP Code
Continued on page 2 4
REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
OApproved f1 Disapproved CI Class A License 0 Class B License C3 Class C License
Reviewer's Name (please print) Date License Number Effective Date Expiration Date
ADOR 10334 (1/14)
Previous 71-1010 (4/06)

Applicants Name as shown on page 1)
0 ki L4 / 3 ad7/1,511 dO APPLICATION FOR BINGO LICENSE
9 Class B and Class C license applicants only: Bingo checking account information:
10 Class B and Class C license applicants only: Bingo interest-bearing account information:
Account Number 'Bank Name
11 Class B and Class C license applicants only: List all officers and/or supervisors authorized to sign checks from the accounts
listed above. If applying as a qualified organization, all supervisors must be members of the applicant:
11a Name 11b Name
David S. Mork
Title Title
Treasurer
Address — Number and Street, Rural Rt., Apt. No. Address — Number and Street, Rural Rt., Apt. No.
City State ZIP Code City State ZIP Code
12 List the name(s) of the one or two persons who will serve as managers. If applying as a qualified organization, these persons
must be members of the applicant. Each person must submit an affidavit.
12a Name 12b Name
Ed Anderson
Title Title
President
Address — Number and Street, Rural Rt., Apt. No. Address — Number and Street, Rural Rt., Apt. No.
City State ZIP Code City State ZIP Code
13 List the name of the one person designated as proceeds coordinator. If applying as a qualified organization, this person must be
an officer or director and a member of the applicant. Each person must submit an affidavit.
Name Address — Number and Street, Rural Rt., Apt. No.
David S. Mork
Title Ci State ZIP Code
Treasurer
14 List the name(s) of the person(s) who will serve as supervisor. If applying as a qualified organization, each person must be a
member of the applicant. Each person must submit an affidavit.
14a Name 14b Name
Peter Meade Billy B. Crump
Title Title
Member President Elect
Address — Number and Street, Rural Rt., Apt. No. Address — Number and Street, Rural Rt., Apt. No.
City State ZIP Code City State ZIP Code
14c Name 14d Name
Title Title
Address — Number and Street, Rural Rt., Apt. No. Address — Number and Street, Rural Rt., Apt. No.
City State ZIP Code City State ZIP Code
ADOR 10334(1/14) Arizona Form 833 Page 2 of 5
Previous 71-1010 (4/06)

Applicant's Name (as shown on page 1)
LI-de S 74447 APPLICATION FOR BINGO LICENSE
15 List the name(s) of the person(s) who will serve as assistants. If applying as a qualified organization, each person must be a
member or new member of the applicant. Except for "Class A" licensees, each person must submit an affidavit,
15a Name 15b Name
DeAnne Rasmussen Donald Prestin
15c Name 15d Name
Rowin Floth William Schink
15e Name 15f Name
Frank Wiley Mark Stapels
15g Name 1 hbLme
Jon Lyons I --t i '4/ 71,4 6 R , S.
16 Street address of the physical location where bingo will be played:
Oakwood Ballroom -24218 S Oakwood Blvd. Sun Lakes, AZ 85248
17 Indikate the tine on each respective day that bingo will be played:
S I MON TUE WED THUR FRI SAT
• a.m. 750 Dam. • a.m. • a.m. • a.m. • a.m. • a.m.
.00 r4 pm P 1g pm p EIP M ' Up m , • p m I I p m , p.m.
18 Liidates of proposed game cancellation if any:
Only If Sunday falls on a holiday or if the ballroom is otherwise booked for an event.
19 Indicate the type of premises where bingo will be played. Check one box:
a 0..4 Neither rent nor mortgage will be paid from bingo funds.
b In Rented or leased. Attach rental affidavit and copy of rental agreement,
Landlord's Name Address — Number and Street, Rural Rt., Apt. No.
Telephone Number (with area code) City State ZIP Code
c J Owned solely by the organization. Attach cony of mortgage, deed of trust, purchase agreement, escrow agreement, or
other related document:
Holder of Mortgage Address — Number and Street, Rural Rt., Apt No.
Telephone Number (with area code) City State ZIP Code
d rl Owned jointly with other organization. Attach copy of mortgage, deed of trust, purchase agreement, escrow agreement, or
other related document:
1) Holder of Mortgage Address — Number and Street, Rural Rt., Apt. No.
Telephone Number (with area code) City State ZIP Code
2) Co-Owner Holder: Address — Number and Street, Rural Rt., Apt. No.
Telephone Number (with area code) City State ZIP Code
3) Co-Owner Holder: Address — Number and Street, Rural Rt., Apt. No.
Telephone Number (with area code) City State ZIP Code
Continued on page 4 4
ADOR 10334(1/14) Arizona Form 833 Page 3 of 5
Previous 71-1010 (4/06)

Applicant's Name (as shown on page 1)
UkJ 2-41-14..S aerTA-61-7 APPLICATION FOR BINGO LICENSE
20 List bingo licensees who are or will be conducting bingo in the same premises as you and those licensees located within 1,000
feet of your _ premises:
20a Name 20b Name
N/A N/A
Address - Number and Street, Rural Rt., Apt. No. Address - Number and Street, Rural Rt., Apt. No.
City State ZIP Code City State ZIP Code
21 Expected bingo expenses:
a Mortgage: $ig , per month
Payable to Address - Number and Street, Rural Rt., Apt. No.
Telephone number (with area code) City State ZIP Code
b Rent: , per X month CI hour 171 occasion
Payable to Address - Number and Street, Rural Rt., Apt. No.
Telephone number (with area code) City State ZIP Code
c Janitorial Services: $,0 per x month hour ri occasion
Payable to Address - Number and Street, Rural Rt., Apt. No.
Telephone number (with area code) City State ZIP Code
d Accounting Services: $0 , per X month 171 hour 1:1 occasion
Payable to Address - Number and Street, Rural Rt., Apt. No.
Telephone number (with area code) City State ZIP Code
e Security Services: , per X month CI hour ri occasion
Payable to Address - Number and Street, Rural Rt., Apt. No.
Telephone number (with area code) City State ZIP Code
f Bingo Supplies: , per
Payable to Address - Number and Street, Rural Rt., Apt. No.
Telephone number (with area code) City State ZIP Code
Line 21 continues on page 5 -)
ADOR 10334(1/14) Arizona Form 833 Page 4 of 5
Previous 71-1010 (4106)

Applicant's Name (as hown on age 1)
L-P-te Y41111 (//fi APPLICATION FOR BINGO LICENSE
21 Expected Bingo Expenses, continued...
g Maximum prize payout per occasion: & . Attach game schedule that lists individual prize amounts.
Paid to Address — Number and Street, Rural Rt., Apt. No.
Telephone number (with area code) City State ZIP Code
h Utility Expenses:
Electric (payable to) Address — Number and Street, Rural Rt., Apt. No.
Account Number Monthly Amount City State ZIP Code
$
Gas (payable to) Address — Number and Street, Rural Rt., Apt. No.
Account Number Monthly Amount City State ZIP Code
$
Water (payable to) Address — Number and Street, Rural Rt., Apt. No.
Account Number Monthly Amount City State ZIP Code
$
Trash Removal (payable to) Address — Number and Street, Rural Rt., Apt. No.
Account Number Monthly Amount City State ZIP Code
$
22 Briefly state the specific projected use of net proceeds from games of bingo:
Support of Rotary Club programs within the Chandler Unified School District and our Veterans outreach programs.
I, Peter Meade , under penalty of perjury and upon oath, declare that I am duly authorized to sign
and file this application. I hereby swear or confirm that I have read the foregoing application and know the contents thereof and that
all information provided has been fully, accurately, and truthfully completed to the best of my knowledge.
Past President
APPLICANTS SIGNATURE TITLE
Please mail to: Arizona Department of Revenue, PO Box 29019, Phoenix, AZ 85038 -9019
n (602) 716-7801
ADOR 10334 (1/14) Arizona Form 833 Page 5 of 5
Previous 71-1010 (4/06)

Arizona Form 832 Endorsement by Local Governing Body Bingo
FOR OFFICIAL USE ONLY PURSUANT TO A.R.S. § 5-404.A
• License Applicants: Complete lines 2, 3, and 4. Submit with entire license package to local governing body.
• Local Governing Body: Complete and return with license package to the Department of Revenue Bingo Section.
License Number
arkew Application Change of Location ‹gi/
Date6
From (Name of local governing body)
nkol rA un,r1-7 ),(0/1-7(C))O9 ,<a(?-4,),-) S oyzS REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
Address (number and street, PO Box) 88
.369 1 W Fiv7 /0 / 0 0
State ZIP Code
qco 0 -s
Phone No. (with area code)
81 PM 80 RCVD
1 This is to certify that on I I I I a hearing was conducted pursuant to Arizona Revised Statute, Title 5,
Chapter 4, in the matter of:
CI Application for a bingo license by the following applicant.
o Application for a bingo license location transfer.
2 Applicant's Name
L-7f 1 L'e 5 Lj(-6cr
3 Location/Adtpss where games will be conducted: City State ZIP Code
443 4/4 Aivo 1") 61-V f) Aa s- 2-1/41
4 Fill in the time on the days games will be played:
SUN MON TUE WED THUR FRI SAT
Dam. h () ,' pp Dam. Da.m. • a.m. • a.m. Dam. • a.m.
Rpm ,..5/71 -70 in , , Op m , • p m Rpm , i Op m , • p.m.
'
5 Background investigations:
have 0 have not been conducted on all individuals listed in the Bingo License Application.
6 Recommendation for the application: El Approved 0 Disapproved
7 Specific reasons for disapproval are hereby listed pursuant to A.R.S. § 5-404.1:
This endorsement must be signed by a delegated authority of the local governing body.
PRINTED NAME
SIGNATURE DATE TITLE
Please mail to: Arizona Department of Revenue, PO Box 29019, Phoenix, AZ 85038-9019
ADOR 10326 (1114) rt (602) 716-7801
Previous 71-1002 (4/06)

Arizona Form
Affidavit Bingo
830
This affidavit must be completed by each person who wishes to assist in the conduct of any game of bingo. If any information is blank or incorrect, the
affidavit will be returned to you All information is subject to verification. Disclosure of your Social Security Number (SSN) is voluntary This information
may be used to establish positive identification for purposes of criminal background checks pursuant to Arizona Revised Statutes § 5-404.
Sun Lakes Rotary Club
Affiant's Name
Mark Stapels
11111111111111
SItp
iliMm
Work Phone No (with arerd- ) e RCVD
1111111.111111______J
If licensee is a qualified organization, the following section is required:
Iviernoer? Date Joined Organization
lZ) Yes Ell No 0 143420 1 8
Officers? Officer Title
0 Yes fe±,12
Do you have an affidavit on file for any other licensee?
EI Yes k No If "Yes", list license number(s):
• Position: Proceeds Coordinator
the above-named affiant, under penalty of perjury, upon
AFFIMITS NAME
oath, depose and say that I will use net proceeds in compliance with the terms of the license, Arizona Revised Statutes,
Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted
of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or
supervisor on another bingo license. I hereby swear or confirm that I have read and understand the foregoing and verify
that the information and statements made herein are true and correct to the best of my knowledge.
Signature of Affiant
Date
0 Position: Manager
I, • the above-named affiant, under penalty of perjury, upon oath,
AFFIAM'S NAME
depose and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license,
Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have
never been convicted of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager,
proceeds coordinator or supervisor on another bingo license. I hereby swear or confirm that I have read and understand
the foregoing and verify that the information and statements made herein are true and correct to the best of my knowledge.
Signature of Affiant
Date
ADOR 10327 (12/18)

.Affiant s Name (as shown on page 1)
[Mark Stapels Bingo Affidavit
Position: Supervisor
• the above-named affiant, under penalty of perjury, upon oath,
A.FTIATirsfm.IE
depose and say that I will be continuously present on the premises during all bingo games and until all associated activities
have been completed in compliance with the terms of the license, Arizona Revised Statutes, Title 5, Chapter 4, and the
rules of the licensing authority. I am of good moral character and have never been convicted of any misdemeanor involving
moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or supervisor on another bingo
license. I hereby swear or confirm that I have read and understand the foregoing and verify that the information and
statements made herein are true and correct to the best of my knowledge.
Mark Stapels , the above-named affiant, under penalty of perjury, upon oath,
AFFIGM s NAME
depose and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license,
Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and
have never been convicted of any misdemeanor involving moral turpitude or felony. I hereby swear or confirm that I have
read and understand the foregoing and verify that the information and statements made herein are true and correct to the
best of my knowledge.
Sigrfature of Afhant
5/21/2019
Date
Review Form and Sign Before Submitting Bingo
Customer Service Center
To avoid processing delays and errors, take a few
moments to make sure you have entered all of the Locations
required information and verify that it is accurate.
8:00 a.m. - 5:00 p.m.
Affiant's Signature Monday through Friday
Sign and date the form. (Except legal Arizona state holidays)
The form can be: Phoenix Office
Emailed to: 1600 West Monroe
bingo@azdor.gov Phoenix, AZ 85007
Faxed to:
602-716-7973 Bingo
Customer Service Telephone
Mailed to:
Bingo Tax Unit Number
PO Box 29019
Phoenix, AZ 85038-9019 (602) 716-7801
ADOR 10327 (12/18) Page 2

Arizona Form
Affidavit Bingo
830
This affidavit must be completed by each person who wishes to assist in the conduct of any game of bingo If any information is blank or incorrect, the
affidavit will be returned to you All information Is subject to verification. Disclosure of your Social Security Number (SSN) is voluntary This information
may be used to establish positive identification for purposes of criminal background checks pursuant to Arizona Revised Statutes § 5-404.
Licensee's Name
Affiant's Name n VENUE USE ONLY. DO NOT MARK IN THIS AREA.
DeAnne Rasmussen
NM=
6
'1111111 Citv
Work Phone No (with area code) RCVD
If licensee is a qualified organization, the following section is required:
Member? Date Joined Organization
Nj Yes IJNo 101119/11999
Officers? Officer Title
0:4 Yes 0 No Soargent at Arms
Do you have an affidavit on file for any other licensee?
Yes Uk No If "Yes", list license numbet(s):
Ej Position: Proceeds Coordinator
the above-named affiant, under penalty of perjury, upon
AFFIAt IT S NAME
oath, depose and say that I will use net proceeds in compliance with the terms of the license, Arizona Revised Statutes,
Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted
of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or
supervisor on another bingo license. I hereby swear or confirm that I have read and understand the foregoing and verify
that the information and statements made herein are true and correct to the best of my knowledge.
Signature of Affiant
Date
El Position: Manager
the above-named affiant, under penalty of perjury, upon oath,
AFRANT S NAME
depose and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license,
Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have
never been convicted of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager,
proceeds coordinator or supervisor on another bingo license. I hereby swear or confirm that I have read and understand
the foregoing and verify that the information and statements made herein are true and correct to the best of my knowledge.
Signature of Affiant
Date
ADOR 10327 (12118)

cAffiant s Name (as shown on page 1)
DeAnne Rasmussen
Position: Supervisor
, the above-named affiant, under penalty of perjury, upon oath,
S ttA,1t
depose and say that I will be continuously present on the premises during all bingo games and until all associated activities
have been completed in compliance with the terms of the license, Arizona Revised Statutes, Title 5, Chapter 4, and the
rules of the licensing authority. I am of good moral character and have never been convicted of any misdemeanor involving
moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or supervisor on another bingo
license. I hereby swear or confirm that I have read and understand the foregoing and verify that the information and
statements made herein are true and correct to the best of my knowledge.
Signature of Affront
Date
Position: Assistant
1, DeAnne Rasmussen , the above-named affiant, under penalty of perjury, upon oath,
AFFLANTS tiAME
depose and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license,
Arizona Revised Statutes, 'Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and
have never been convicted of any misdemeanor involving moral turpitude or felony. I hereby swear or confirm that I have
read and understand the foregoing and verify that the information and statements made herein are true and correct to the
best of my knowledge.
Review Form and Sign Before Submitting Bingo
Customer Service Center
To avoid processing delays and errors, take a few
moments to make sure you have entered all of the Locations
required information and verify that it is accurate.
8:00 a.m. - 5:00 p.m.
Affiant's Signature Monday through Friday
Sign and date the form. (Except legal Arizona state holidays)
The form can be: Phoenix Office
1600 West Monroe
Emailed to:
bingo@azdorgov Phoenix, AZ 85007
Faxed to: Bingo
602-716-7973
Customer Service Telephone
Mailed to: Number
Bingo Tax Unit
PO Box 29019
Phoenix, AZ 85038-9019 (602) 716-7801
ADOR 10327 (12/18) Page 2

Affidavit Bingo
This affidavit must be completed by each person who wishes to assist in the conduct of any game of bingo If any information is blank or incorrect, the
affidavit will be returned to you All information is subject to verification Disclosure of your Social Security Number (SSN) is voluntary This information
may be used to establish positive identification for purposes of criminal background checks pursuant to Arizona Revised Statutes § 5-404.
Licensee's Name License Number
Sun Lakes Rotary Club
Affiant's Name ti VENUE USE ONLY. DO NOT MARK IN THIS AREA.
David S Mork
1111111111111111,
81 PM RCVD
If licensee is a qualified organization, the fol
Member? Date Joined Organization
El Yes D No 1112_,V005
Officers'? Officer Title
IN Yes DNo Treasurer
Do you have an affidavit on file for any other licensee'?
0 S No If "Yes", list license number(s),
IN Position: Proceeds Coordinator
I, David S. Mork , the above-named affiant, under penalty of perjury, upon
AFFIANT'S NAME
oath, depose and say that I will use net proceeds in compliance with the terms of the license, Arizona Revised Statutes,
Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted
of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or
supervisor on another bingo license. I hereby swear or confirm that I have read and understand the foregoing and verify
that the information and statements made herein are true and c ect to the •est of my knowle e.
4114 I 1111k .4 i
Signature of Affiant
Th- .21 c2,
Date
• Position: Manager
, the above-named affiant, under penalty of perjury, upon oath,
AFFIANT'S NAME
depose and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license,
Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have
never been convicted of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager,
proceeds coordinator or supervisor on another bingo license. I hereby swear or confirm that I have read and understand
the foregoing and verify that the information and statements made herein are true and correct to the best of my knowledge.
Signature of Affiant
Date
ADOR 10327 2/18)

Arizona Form
Affidavit Bingo
830
This affidavit must be completed by each person who wishes to assist in the conduct of any game of bingo. If any information is blank or incorrect, the
affidavit will be returned to you. All information is subject to verification. Disclosure of your Social Security Number (SSN) is voluntary. This information
may be used to establish positive identification for purposes of criminal background checks pursuant to Arizona Revised Statutes § 5-404.
Licensee's Name License Number
iCe4 Cf. /4_6;4- Aara
n
vENUE USE ONLY. DO NOT MARK IN THIS AREA.
If licensee is a qualified organization, the following section is required:
Member? Date Joined Organization
14 Yes DN0 lj'A 1:26/ 6—
Officers? Officer The
ayes El No rL6i .1,71
Do you have an affidavit on file for any other licensee?
El Yes [It No If "Yes", list license number(s):
• Position: Proceeds Coordinator
the above-named affiant, under penalty of perjury, upon
AFFIANTS NAME
oath, depose and say that I will use net proceeds in compliance with the terms of the license, Arizona Revised Statutes,
Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted
of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or
supervisor on another bingo license. I hereby swear or confirm that I have read and understand the foregoing and verify
that the information and statements made herein are true and correct to the best of my knowledge.
Signature of Affiant
Date
IA Position: Manager
I, I: 4-1-1 ci e- Y /- 5 e."-YIJ , the above-named affiant, under penalty of perjury, upon oath,
AFFIANTS NAME
depose and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license,
Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have
never been convicted of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager,
proceeds coordinator or supervisor on another bingo license. I hereby swear or confirm that I have read and understand
the foregoing and verify that the information and statements made herein are true and correct to the best of my knowledge.
ignature o A ant
Ls'A i)/1
Date
ADOR 10327 (12/18)

Arizona Form
Affidavit Bingo
830
This affidavit must be completed by each person who wishes to assist in the conduct of any game of bingo If any information is blank or incorrect, the
affidavit will be returned to you All information is subject to verification Disclosure of your Social Security Number (SSN) is voluntary This information
may be used to establish positive identification for purposes of criminal background checks pursuant to Arizona Revised Statutes § 5-404
Licensee's Name License Number
Sun Lakes Rotary Club
1_ Affrant's Name t VENUE USE ONLY. DO NOT MARK IN THIS AREA.
Peter Meade
11111111111M AIM
Work Phone No vim area code)
If licensee is a qualified organization, the following section is required:
Member? Date Joined Organization
w Yes No 10/±31/12016
Officers? Officer Title
CI Yes gl No
Do you have an affidavit on file for any other licensee?
El Yes _JNo If "Yes", list license number(s):
0 Position: Proceeds Coordinator
the above-named affiant, under penalty of perjury, upon
AFFIANTS tlALIE
oath, depose and say that I will use net proceeds in compliance with the terms of the license, Arizona Revised Statutes,
Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted
of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or
supervisor on another bingo license. I hereby swear or confirm that I have read and understand the foregoing and verify
that the information and statements made herein are true and correct to the best of my knowledge.
Signature of Affrant
Date
0 Position: Manager
the above-named affiant, under penalty of perjury, upon oath,
AFRAFIT'S NAME
depose and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license,
Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have
never been convicted of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager,
proceeds coordinator or supervisor on another bingo license. I hereby swear or confirm that I have read and understand
the foregoing and verify that the information and statements made herein are true and correct to the best of my knowledge.
Signature of Affiant
Date
ADOR 10327 (12118)

rAffiant's Name (as shown on page 1) Bingo Affidavit
[Peter Meade
, the above-named affiant, under penalty of perjury, upon oath,
S NAME
depose and say that I will be continuously present on the premises during all bingo games and until all associated activities
have been completed in compliance with the terms of the license, Arizona Revised Statutes, Title 5, Chapter 4, and the
rules of the licensing authority. I am of good moral character and have never been convicted of any misdemeanor involving
moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or supervisor on another bingo
license. I hereby swear or confirm that I have read and understand the foregoing and verify that the information and
statements made herein are true and correct to the best of my knowled
0 Position: Assistant
, the above-named affiant, under penalty of perjury, upon oath,
AFFLA1IUS *WE
depose and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license,
Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and
have never been convicted of any misdemeanor involving moral turpitude or felony. I hereby swear or confirm that I have
read and understand the foregoing and verify that the information and statements made herein are true and correct to the
best of my knowledge.
Review Form and Sign Before Submitting Bingo
Customer Service Center
To avoid processing delays and errors, take a few
moments to make sure you have entered all of the Locations
required information and verify that it is accurate.
8:00 a.m. - 5:00 p.m.
Affiant's Signature Monday through Friday
Sign and date the form. (Except legal Arizona state holidays)
The form can be: Phoenix Office
1600 West Monroe
Emailed to:
bingo@azdor.gov Phoenix, AZ 85007
Faxed to: Bingo
602-716-7973
Customer Service Telephone
Mailed to: Number
Bingo Tax Unit
PO Box 29019
Phoenix, AZ 85038-9019 (602) 716-7801
ADOR 10327 (12/16) Page 2

Arizona Form
Affidavit Bingo
830
This affidavit must be completed by each person who wishes to assist in the conduct of any game of bingo. If any information is blank or incorrect, the
affidavit will be returned to you. All information is subject to verification. Disclosure of your Social Security Number (SSN) is voluntary. This information
may be used to establish positive identification for purposes of criminal background checks pursuant to Arizona Revised Statutes § 5-404.
Licensee's Name License Number
5 v kA 1(65 . i ,hha-Y iv VA
n VENUE USE ONLY. DO NOT MARK IN THIS AREA.
E
If licensee is a qualified organization, the following section is required:
Member? Date Joined Organization
plYes 0 No n 1 It Zor7
Officers? Officer Title
B-Yes U No
Do you have an affidavit on file for any other licensee?
• Yes .0, No If "Yes", list license number(s):
• Position: Proceeds Coordinator
the above-named affiant, under penalty of perjury, upon
AFFIANTS NAME
oath, depose and say that I will use net proceeds in compliance with the terms of the license, Arizona Revised Statutes,
Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted
of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or
supervisor on another bingo license. I hereby swear or confirm that I have read and understand the foregoing and verify
that the information and statements made herein are true and correct to the best of my knowledge.
Signature of Affiant
Date
• Position: Manager
I, , the above-named affiant, under penalty of perjury, upon oath,
AFFIANTS NAME
depose and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license,
Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have
never been convicted of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager,
proceeds coordinator or supervisor on another bingo license. I hereby swear or confirm that I have read and understand
the foregoing and verify that the information and statements made herein are true and correct to the best of my knowledge.
Signature of Affiant
Date
ADOR 10327 (12118)

Affiant's Name (as shown on Raz 1)
Bingo Affidavit
j - <-$ (44- e iJ
El Position: Supervisor
the above-named affiant, under penalty of perjury, upon oath,
AFFIANTS NAME
depose and say that I will be continuously present on the premises during all bingo games and until all associated activities
have been completed in compliance with the terms of the license, Arizona Revised Statutes, Title 5, Chapter 4, and the
rules of the licensing authority. I am of good moral character and have never been convicted of any misdemeanor involving
moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or supervisor on another bingo
license. I hereby swear or confirm that I have read and understand the foregoing and verify that the information and
statements made herein are true and correct to the best of my knowledge.
Signature of Affiant
Date
(152 Position: Assistant
,.,
I, ‘Doi\J A L- r. C 17 X) ; the above-named affiant, under penalty of perjury, upon oath,
AFFIANT'S NAME
depose and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license,
Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and
have never been convicted of any misdemeanor involving moral turpitude or felony. I hereby swear or confirm that I have
read and understand the foregoing and verify that the information and statements made herein are true and correct to the
best of my knowledge.
01 itt) 7/24101" H ‘ '
Signature of Affian
Date
Review Form and Sign Before Submitting Bingo
Customer Service Center
To avoid processing delays and errors, take a few
moments to make sure you have entered all of the Locations
required information and verify that it is accurate.
8:00 a.m. - 5:00 p.m.
Affiant's Signature Monday through Friday
Sign and date the form. (Except legal Arizona state holidays)
The form can be: Phoenix Office
1600 West Monroe
Emailed to:
bingo@azdor.gov Phoenix, AZ 85007
Faxed to: Bingo
602-716-7973
Customer Service Telephone
Mailed to: Number
Bingo Tax Unit
PO Box 29019
Phoenix, AZ 85038-9019 (602) 716-7801
ADOR 10327 (12118) Page 2

Arizona Form
Affidavit Bingo
830
This affidavit must be completed by each person who wishes to assist in the conduct of any game of bingo. If any information is blank or incorrect, the
affidavit will be returned to you. All information is subject to verification. Disclosure of your Social Security Number (SSN) is voluntary. This information
may be used to establish positive identification for purposes of criminal background checks pursuant to Arizona Revised Statutes § 5-404.
Licensee's Name License Number
riFigt-) Cy-a 05
Member? Date Joined Org.arii4altpn
, 'Yes • No 02 levt—I cfg'?
Officers? Officer Title
• Yes „ZNo
Do you have an affidavit on file for any other licensee?
• Yes ,No If "Yes", list license number(s):
• Position: Proceeds Coordinator
I, , the above-named affiant, under penalty of perjury, upon
AFFIANTS NAME
oath, depose and say that I will use net proceeds in compliance with the terms of the license, Arizona Revised Statutes,
Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted
of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or
supervisor on another bingo license. I hereby swear or confirm that I have read and understand the foregoing and verify
that the information and statements made herein are true and correct to the best of my knowledge.
Signature of Affiant
Date
ID Position: Manager
the above-named affiant, under penalty of perjury, upon oath,
AFFIANTS NAME
depose and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license,
Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have
never been convicted of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager,
proceeds coordinator or supervisor on another bingo license. I hereby swear or confirm that I have read and understand
the foregoing and verify that the information and statements made herein are true and correct to the best of my knowledge.
Signature of Affiant
Date
ADOR 10327(12/18)

AffianNlame (as shown on page 1)
Bingo Affidavit
(7,
GI Position: Supervisor
, the above-named affiant, under penalty of perjury, upon oath,
AFFIANTS NAME
depose and say that I will be continuously present on the premises during all bingo games and until all associated activities
have been completed in compliance with the terms of the license, Arizona Revised Statutes, Title 5, Chapter 4, and the
rules of the licensing authority. I am of good moral character and have never been convicted of any misdemeanor involving
moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or supervisor on another bingo
license. I hereby swear or confirm that I have read and understand the foregoing and verify that the information and
statements made herein are true and correct to the best of my knowledge.
Signature of Affiant
Date
lI PositiAssistant
0-0 Pt-cf& , the above-named affiant, under penalty of perjury, upon oath,
AFFIANTS NAME
depose and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license,
Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and
have never been convicted of any misdemeanor involving moral turpitude or felony. I hereby swear or confirm that I have
read and understand the foregoing and verify that the information andzstlements made herein are true and correct to the
best of my knowledge.
10-)91.) ze.2/ T
Date
Review Form and Sign Before Submitting Bingo
Customer Service Center
To avoid processing delays and errors, take a few
moments to make sure you have entered all of the Locations
required information and verify that it is accurate.
8:00 a.m. - 5:00 p.m.
Affiant's Signature Monday through Friday
Sign and date the form. (Except legal Arizona state holidays)
The form can be: Phoenix Office
1600 West Monroe
Emailed to:
bingo@azdor.gov Phoenix, AZ 85007
Faxed to: Bingo
602-716-7973
Customer Service Telephone
Mailed to: Number
Bingo Tax Unit
PO Box 29019
Phoenix, AZ 85038-9019 (602) 716-7801
ADOR 10327(12/18) Page 2

Arizona Form
Affidavit Bingo
830
This affidavit must be completed by each person who wishes to assist in the conduct of any game of bingo. If any information is blank or incorrect, the
affidavit will be returned to you. All information is subject to verification. Disclosure of your Social Security Number (SSN) is voluntary. This information
may be used to establish positive identification for purposes of criminal background checks pursuant to Arizona Revised Statutes § 5-404.
Licensee's Name License Number
Sa I. ft Fte s re rshrst9 c_Lti
Affiant's Name §VENUE USE ONLY. DO NOT MARK IN THIS AREA.
fr.) Pi /4 Sc pfzwile
Sonil Stirilv
Ad r—
City
Work " '":Ith area code)
If licensee is a qualified organization, the following section is required:
Member? Date oined Organization
1E1 Yes 0 No 04 IAC .
Officers? Officer Title
• Yes pi No
Do you have an affidavit on file for any other licensee?
El Yes NI No If "Yes", list license number(s):
El Position: Proceeds Coordinator
I, , the above-named affiant, under penalty of perjury, upon
AFFIANTS NAME
oath, depose and say that I will use net proceeds in compliance with the terms of the license, Arizona Revised Statutes,
Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted
of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or
supervisor on another bingo license. I hereby swear or confirm that I have read and understand the foregoing and verify
that the information and statements made herein are true and correct to the best of my knowledge.
Signature of Affiant
Date
EI Position: Manager
the above-named affiant, under penalty of perjury, upon oath,
AFFIANT'S NAME
depose and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license,
Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have
never been convicted of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager,
proceeds coordinator or supervisor on another bingo license. I hereby swear or confirm that I have read and understand
the foregoing and verify that the information and statements made herein are true and correct to the best of my knowledge.
Signature of Affiant
Date
ADOR 10327(12/18)

Affiant's Name. (as shown on page 1)
Bingo Affidavit
titia 11, 4-A.,
Position: Supervisor
, the above-named affiant, under penalty of perjury, upon oath,
AFFIANT S NAME
depose and say that I will be continuously present on the premises during all bingo games and until all associated activities
have been completed in compliance with the terms of the license, Arizona Revised Statutes, Title 5, Chapter 4, and the
rules of the licensing authority. I am of good moral character and have never been convicted of any misdemeanor involving
moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or supervisor on another bingo
license. I hereby swear or confirm that I have read and understand the foregoing and verify that the information and
statements made herein are true and correct to the best of my knowledge.
Signature of Affiant
Date
a Position: Assistant
lif,,a44,, a. , the above-named affiant, under penalty of perjury, upon oath,
AFFIANTS NAME
depose and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license,
Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and
have never been convicted of any misdemeanor involving moral turpitude or felony. I hereby swear or confirm that I have
read and understand the foregoing and verify that the information and statements made herein are true and correct to the
best of my knowledge.
Review Form and Sign Before Submitting Bingo
Customer Service Center
To avoid processing delays and errors, take a few
moments to make sure you have entered all of the Locations
required information and verify that it is accurate.
8:00 a.m. - 5:00 p.m.
Affiant's Signature Monday through Friday
Sign and date the form. (Except legal Arizona state holidays)
The form can be: Phoenix Office
1600 West Monroe
Emailed to:
bingo@azdor.gov Phoenix, AZ 85007
Faxed to: Bingo
602-716-7973
Customer Service Telephone
Mailed to:
Bingo Tax Unit Number
PO Box 29019
Phoenix, AZ 85038-9019 (602) 716-7801
ADOR 10327 (12/18) Page 2

Arizona Form
Affidavit Bingo
830
This affidavit must be completed by each person who wishes to assist in the conduct of any game of bingo. If any information is blank or incorrect, the
affidavit will be returned to you. All information is subject to verification. Disclosure of your Social Security Number (SSN) is voluntary. This information
may be used to establish positive identification for purposes of criminal background checks pursuant to Arizona Revised Statutes § 5-404.
Licensee's Name CL L.) -23 License Number
U ok)
n
Affiapids Name VENUE USE ONLY. DO NOT MARK IN THIS AREA.
1J C41 i) 1-2
Date of Birth
1111111111111
If licensee is a qualified organization, the following section is required:
Member? Date Joined Organization
71 Yes UNo I I
Officers? Officer Title
' Yes 0 No
Do you have an affidavit on file for any other licensee?
Yes 1, No If "Yes", list license number(s):
CI Position: Proceeds Coordinator
, the above-named affiant, under penalty of perjury, upon
AFFIANT'S NAME
oath, depose and say that I will use net proceeds in compliance with the terms of the license, Arizona Revised Statutes,
Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted
of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or
supervisor on another bingo license. I hereby swear or confirm that I have read and understand the foregoing and verify
that the information and statements made herein are true and correct to the best of my knowledge.
Signature of Affiant
Date
0 Position: Manager
, the above-named affiant, under penalty of perjury, upon oath,
AFFIANT'S NAME
depose and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license,
Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have
never been convicted of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager,
proceeds coordinator or supervisor on another bingo license. I hereby swear or confirm that I have read and understand
the foregoing and verify that the information and statements made herein are true and correct to the best of my knowledge.
Signature of Affiant
Date
ADOR 10327 (12/18)

Affiant's Name (as shown 1) ,...„
1/1 Bingo Affidavit
Position: Supervisor
I , 13', n y 3. u iP , the above-named affiant, under penalty of perjury, upon oath,
AFFIANT'S NAME
depose and say that I will be continuously present on the premises during all bingo games and until all associated activities
have been completed in compliance with the terms of the license, Arizona Revised Statutes, Title 5, Chapter 4, and the
rules of the licensing authority. I am of good moral character and have never been convicted of any misdemeanor involving
moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or supervisor on another bingo
license. I hereby swear or confirm that I have read and understand the foregoing and verify that the information and
statements made herein are true and correct to the best of my knowledge.
Sign ))))IIff
Date
El Position: Assistant
, the above-named affiant, under penalty of perjury, upon oath,
AFFIANT'S NAME
depose and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license,
Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and
have never been convicted of any misdemeanor involving moral turpitude or felony. I hereby swear or confirm that I have
read and understand the foregoing and verify that the information and statements made herein are true and correct to the
best of my knowledge.
Signature of Affiant
Date
Review Form and Sign Before Submitting Bingo
Customer Service Center
To avoid processing delays and errors, take a few
moments to make sure you have entered all of the Locations
required information and verify that it is accurate.
8:00 a.m. - 5:00 p.m.
Affiant's Signature Monday through Friday
Sign and date the form. (Except legal Arizona state holidays)
The form can be: Phoenix Office
1600 West Monroe
Emailed to:
bingo@azdor.gov Phoenix, AZ 85007
Faxed to: Bingo
602-716-7973
Customer Service Telephone
Mailed to: Number
Bingo Tax Unit
PO Box 29019
Phoenix, AZ 85038-9019 (602) 716-7801
ADOR 10327 (12/18) Page 2

Arizona Form
Affidavit Bingo
830
This affidavit must be completed by each person who wishes to assist in the conduct of any game of bingo. If any information is blank or incorrect, the
affidavit will be returned to you. All information is subject to verification. Disclosure of your Social Security Number (SSN) is voluntary. This information
may be used to establish positive identification for purposes of criminal background checks pursuant to Arizona Revised Statutes § 5-404.
Licensee's Name License Number
5'04 ;?0'77, (kg
a
gr.0 (L27' VENUE USE ONLY. DO NOT MARK IN THIS AREA.
Home Phone No. (with area code)
If licensee is a qualified organization, the following section is required:
riAtber?
Yes 0 No
Officers?
Dyes 0
Do you have anAffldavit on file for any other licensee?
0 Yes No If "Yes", list license number(s):
• Position: Proceeds Coordinator
I, , the above-named affiant, under penalty of perjury, upon
AFFIANTS NAME
oath, depose and say that I will use net proceeds in compliance with the terms of the license, Arizona Revised Statutes,
Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted
of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or
supervisor on another bingo license. I hereby swear or confirm that I have read and understand the foregoing and verify
that the information and statements made herein are true and correct to the best of my knowledge.
Signature of Affiant
Date
• Position: Manager
I, , the above-named affiant, under penalty of perjury, upon oath,
AFRANTS NAME
depose and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license,
Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have
never been convicted of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager,
proceeds coordinator or supervisor on another bingo license. I hereby swear or confirm that I have read and understand
the foregoing and verify that the information and statements made herein are true and correct to the best of my knowledge.
Signature of Affiant
Date
ADOR 10327 (12/18)

Affiant's Name (as shown on page 1)
FIC4 X Bingo Affidavit
/91
ID Position: Supervisor
I, , the above-named affiant, under penalty of perjury, upon oath,
AFFIANTS NAME
depose and say that I will be continuously present on the premises during all bingo games and until all associated activities
have been completed in compliance with the terms of the license, Arizona Revised Statutes, Title 5, Chapter 4, and the
rules of the licensing authority. I am of good moral character and have never been convicted of any misdemeanor involving
moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or supervisor on another bingo
license. I hereby swear or confirm that I have read and understand the foregoing and verify that the information and
statements made herein are true and correct to the best of my knowledge.
Signature of Affiant
Date
X Position: Assistant
ZAPV-- ,apic*- Km—,00,y,
I, the above-named affiant, under penalty of perjury, upon oath,
AFFIANTS NAME
depose and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license,
Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and
have never been convicted of any misdemeanor involving moral turpitude or felony. I hereby swear or confirm that I have
read and understand the foregoing and verify that the information and statements made herein are true and correct to the
best of my knowledge. ,
r-,
A41-1/1—
Signature /Twit /
Date
Review Form and Sign Before Submitting Bingo
Customer Service Center
To avoid processing delays and errors, take a few
moments to make sure you have entered all of the Locations
required information and verify that it is accurate.
8:00 a.m. - 5:00 p.m.
Affiant's Signature Monday through Friday
Sign and date the form. (Except legal Arizona state holidays)
The form can be: Phoenix Office
1600 West Monroe
Emailed to:
bingo@azdor.gov Phoenix, AZ 85007
Faxed to: Bingo
602-716-7973
Customer Service Telephone
Mailed to:
Bingo Tax Unit Number
PO Box 29019
Phoenix, AZ 85038-9019 (602) 716-7801
ADOR 10327 (12118) Page 2

Arizona Form
Affidavit Bingo
830
This affidavit must be completed by each person who wishes to assist in the conduct of any game of bingo. If any information is blank or incorrect, the
affidavit will be returned to you. All information is subject to verification. Disclosure of your Social Security Number (SSN) is voluntary. This information
may be used to establish positive identification for purposes of criminal background checks pursuant to Arizona Revised Statutes § 5-404.
Licensee's Name License Number
vAI t4- 144 ge5 7/4-4-r' Z-L,
n
Affiant's Name vENUE USE ONLY. DO NOT MARK IN THIS AREA.
1,-n)
11111111111111I
lif--1•1111-11111---111
Work Phone No. (with area code)
If licensee is a qualified organization, the following section is required:
Member? Date Joined Organization
Yes • No 7i 1 1 2c i -7
gr ficers? Officer Title
Yes p No -
Do you have an affidavit on file for any other licensee?
• Yes 0 No If "Yes", list license number(s):
• Position: Proceeds Coordinator
the above-named affiant, under penalty of perjury, upon
AFFIANTS NAME
oath, depose and say that I will use net proceeds in compliance with the terms of the license, Arizona Revised Statutes,
Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted
of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or
supervisor on another bingo license. I hereby swear or confirm that I have read and understand the foregoing and verify
that the information and statements made herein are true and correct to the best of my knowledge.
Signature of Affiant
Date
Position: Manager
the above-named affiant, under penalty of perjury, upon oath,
AFFIANTS NAME
depose and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license,
Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have
never been convicted of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager,
proceeds coordinator or supervisor on another bingo license. I hereby swear or confirm that I have read and understand
the foregoing and verify that the information and statements made herein are true and correct to the best of my knowledge.
Signature of Affiant
Date
ADOR 10327(12/18)

Affiant's Name (as shown on page 1)
'4) IIyfrV s Bingo Affidavit
• Position: Supervisor
the above-named afflant, under penalty of perjury, upon oath,
AFFIANTS NAME
depose and say that I will be continuously present on the premises during all bingo games and until all associated activities
have been completed in compliance with the terms of the license, Arizona Revised Statutes, Title 5, Chapter 4, and the
rules of the licensing authority. I am of good moral character and have never been convicted of any misdemeanor involving
moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or supervisor on another bingo
license. I hereby swear or confirm that I have read and understand the foregoing and verify that the information and
statements made herein are true and correct to the best of my knowledge.
Signature of Affiant
Date
0 Position: Assistant
0 -N) L GA-) '5 , the above-named affiant, under penalty of perjury, upon oath,
IANT'S NAME
depose and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license,
Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and
have never been convicted of any misdemeanor involving moral turpitude or felony. I hereby swear or confirm that I have
read and understand the foregoing and verify that the information and statement made herein are true and correct to the
best of my knowledge.
Signature of Affi
2-1 /Z,r/'
Date
Review Form and Sign Before Submitting Bingo
Customer Service Center
To avoid processing delays and errors, take a few
moments to make sure you have entered all of the Locations
required information and verify that it is accurate.
8:00 a.m. - 5:00 p.m.
Affiant's Signature Monday through Friday
Sign and date the form. (Except legal Arizona state holidays)
The form can be: Phoenix Office
1600 West Monroe
Emailed to:
bingo@azdor.gov Phoenix, AZ 85007
Faxed to: Bingo
602-716-7973
Customer Service Telephone
Mailed to:
Bingo Tax Unit Number
PO Box 29019
Phoenix, AZ 85038-9019 (602) 716-7801
ADOR 10327 (12/18) Page 2

Arizona Form
Affidavit Bingo
830
This affidavit must be completed by each person who wishes to assist in the conduct of any game of bingo. If any information is blank or incorrect, the
affidavit will be returned to you. All information is subject to verification. Disclosure of your Social Security Number (SSN) is voluntary. This information
may be used to establish positive identification for purposes of criminal background checks pursuant to Arizona Revised Statutes § 5-404.
License Number
inVENUE USE ONLY. DO NOT MARK IN THIS AREA.
Ad
F-1111111-111111111'111
1-11111111F--7111111111
If licensee is a qualified organization, the following section is required:
Member? Date Joined Organization
El Yes 0 No
Officers? Officer Title
0 Yes 0 No
Do you have an affidavit on file for any other licensee?
0 Yes 0 No If "Yes", list license number(s):
El Position: Proceeds Coordinator
the above-named affiant, under penalty of perjury, upon
AFFIANT'S NAME
oath, depose and say that I will use net proceeds in compliance with the terms of the license, Arizona Revised Statutes,
Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted
of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or
supervisor on another bingo license. I hereby swear or confirm that I have read and understand the foregoing and verify
that the information and statements made herein are true and correct to the best of my knowledge.
Signature of Affiant
Date
El Position: Manager
the above-named affiant, under penalty of perjury, upon oath,
AFFIANT S NAME
depose and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license,
Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have
never been convicted of any misdemeanor involving moral turpitude or felony. I am not currently serving as a manager,
proceeds coordinator or supervisor on another bingo license. I hereby swear or confirm that I have read and understand
the foregoing and verify that the information and statements made herein are true and correct to the best of my knowledge.
Signature of Affiant
Date
ADOR 10327 (12/18)

AffiagkName (as shown on page 1)
oZ Bingo Affidavit
,
OA Position: Supervisor
----7 1 --7---7-be
I, I I"- / i--- n— kl / f Ovteil S , the above-named affiant, under penalty of perjury, upon oath,
AFFIANT'S NAME
depose and say that I will be continuously present on the premises during all bingo games and until all associated activities
have been completed in compliance with the terms of the license, Arizona Revised Statutes, Title 5, Chapter 4, and the
rules of the licensing authority. I am of good moral character and have never been convicted of any misdemeanor involving
moral turpitude or felony. I am not currently serving as a manager, proceeds coordinator or supervisor on another bingo
license. I hereby swear or confirm that I have read and understand the foregoing and verify that the information and
statements made herein are true and correct to the best of my knowledge.
gnature of Affia
Date
El Position: Assistant
I, , the above-named affiant, under penalty of perjury, upon oath,
AFFIANT'S NAME
depose and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license,
Arizona Revised Statutes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and
have never been convicted of any misdemeanor involving moral turpitude or felony. I hereby swear or confirm that I have
read and understand the foregoing and verify that the information and statements made herein are true and correct to the
best of my knowledge.
Signature of Affiant
Date
Review Form and Sign Before Submitting Bingo
Customer Service Center
To avoid processing delays and errors, take a few
moments to make sure you have entered all of the Locations
required information and verify that it is accurate.
8:00 a.m. - 5:00 p.m.
Affiant's Signature Monday through Friday
Sign and date the form. (Except legal Arizona state holidays)
The form can be: Phoenix Office
1600 West Monroe
Emailed to:
bingo@azdor.gov Phoenix, AZ 85007
Faxed to: Bingo
602-716-7973
Customer Service Telephone
Mailed to: Number
Bingo Tax Unit
PO Box 29019
Phoenix, AZ 85038-9019 (602) 716-7801
ADOR 10327 (12/18) Page 2