ORIGINAL PALM VALLEY- 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.
information is subject to verification. If you need more space, attach additional sheets. All
v • 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 Appl'cant's Name n
lq-L-4-61 1141-ms Falsification of information
2a Mailing Address contained in this application
,R5 $0o. Wild S& 'j constitutes a Class 6 felony.
2b City,_ State ZIP Code REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
M6-56 88
3a Administrative Office Location
3b City State ZIP Code
4a Name of Contact Person
4c E-mai 1^ Oa--S ; ' ANY) SO4 11 111 111 .1111
4c Fax No.
5 Class B and Class C license applicants only: If applying as a qualified organization, check one box to indicate the type of
organization:
o Charitable 0 Social 0 Religious 0 Veterans
0 Fraternal 0 Volunteer Fire Department 0 Homeowners Association 0 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
Address —Number and Street, Rural Rt., Apt. No. Address—Number and Street, Rural Rt., Apt. No.
City State ZIP Code City State ZIP Code
7 Class B and Class C license applicants only applying as a qualified organization, provide the date the organization was
established In Arizona: • •
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
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
8c Name 8d 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
ontinued on page
REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
ilApproved Ci Disapproved 10 Class A License El Class B License ri Class C License
Reviewer's Name (please print) Date License Number Effective Date Expiration Date
AIDOR 10334 (1114)
Previous 71-1010(4/06)

Applicant's Name (as shown pg page 1)
VAL...t.ey 41._
APPLICATION FOR BINGO LICENSE
9 Class B and Class C license applicants only: Bingo checking account information:
Checking Account Number Bank Name Bank Branch
10 Class B and Class C license applicants only: Bingo interest-bearing account information:
Account Number Bank Name Bank Branch
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 lib 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
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.
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.
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 Na e idb Name
ii athle.- it#Weite r -5 ell BO (01 t O i`rve,
Title Title
ICIVI5oer
Ad Ad _ .._ _ • --.
iii immffis
14aNameo
Del re,5 S 'efh
Title z'.
Nt /
Cr V/15Or ljilMIEIIIIIIIIIIIIIIIIIIIIII
r"gir
Ci
ADOR 10334 (1114) Arizona Form 833 Page 2 of 5
Previous 71-1010(4/06)

ApplIcant:s iNarne (as shows n page 1)
V61/0 r
APPLICATION FOR BINGO LICENSE
16 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
15c Name 15d Name
15e Name 15f Name
15g Name 15h Name
16 Street address of the physical location where bingo will be played.._ /0a.?ra )9,1c5_a. 62. s3;24sr.
17
SUN MON TUE WED THUR FRI SAT
Dam. Dam. , .2 Ela.m. • a.m. Dam. • a.m. Da.m.
, 1 Rpm IOP m i b 1=7Ci 1* rn P 'OP M f . Rpm . 'DO m 1 , El P.m.
18 List dates of proposed game cancellation if any:
19 Indicate the type of premises where bingo will be played. Check one box:
a Neither rent nor mortgage will be paid from bingo funds.
b ri 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 fl Owned solely by the organization. Attach ,copy 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 C3 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 RI, 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 (1114) Arizona Form 833 Page 3 of 5
Previous 71-1010(4/06)

Applicant' Name (as sh(Mi op page 1)
Vailty /41Th 5 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 I 20b Name
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 Mortaaoe: per month
Payable to Address — Number and Street, Rural Rt., Apt. No.
Telephone number (with area code) City State ZIP Code
b Rent: , per in month 0 hour 0 occasion
Payable to Address — Number and Street, Rural Rt., Apt. No.
Telephone number (with area code) City State ZIP Code
c Janitorial Services: , Ii , per (71 month 0 hour CI occasion
Payable to Address — Number and Street, Rural Rt., Apt. No.
Telephone number (with area code) City State ZIP Code
d Accounting Services: $, 144 , per 1:3 month r3 hour El occasion
Payable to Address — Number and Street, Rural Rt., Apt. No.
Telephone number (with area code) City State ZIP Code
e Security Services: per 0 month 0 hour 0 occasion
Payable to Address — Number and Street, Rural Rt., Apt. No.
Telephone number (with area code) City State ZIP Code
f Binao Suoolies: $5OO per ea.fre"
Payabled: ei h i / Address — Number and Street, Rural Rt., I. No.
S f)//7 1 Skpa01/ 3,) 0 e; Af'dese-1-- Rci'
Telephoine number (with area 4. City A i State ZIP Code
be- olk g - agzi r WC/7 i X 4'2710
Line 21 continues on page 5 4
ADOR 10334 (1114) Arizona Form 833 Page 4 of 5
Previous 71-1010 (4/06)

Applicant's Ne om (as shown onTage 1)
Vaiky Nrnc APPLICATION FOR BINGO LICENSE
21 Expected Bingo Expenses, continued...
g Maximum prize payout per occasion: sir-71,00°-=: . 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.
NM
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) N A„ 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:
,iiilapeeme./171 a elf- 46b'vihe5 /I/1 e6hynamly,
tealS '7 lionipseh , 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.
117_2711 ,.1.
APPLICANTS SIGNATURE TITLE
Please mail to: Arizona Department of Revenue, PO Box 29019, Phoenix, 85038-9019
fit (602) 716-7801
ADOR 10334 (1114) Arizona Form 833 Page 5 of 5
Previous 71-1010(4106)

/AVOgiti Endorsement by Local Governing Body Bingo
FOR OFFICIAL USE ONLY PURSUANT TO A.R.S. § 5-404.A
0 License Applicants: Complete lines 2, 3, and 4. Submit with entire license package to local governing body.
0 Local Governing Body: Complete and return with license package to the Department of Revenue Bingo Section.
Date License Number
New Application 1:1 Change of Location
From (Name of local governing body)
REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
Address (number and street, PO Box) T3-81
City State ZIP Code
Phone No. (with area code)
I This is to certify that on I I I la hearing was conducted pursuant to Arizona Revised Statute, Title 5,
Chapter 4, in the matter of:
0 Application for a bingo license by the following applicant,
0 Application for a bingo license location transfer.
2 Applicant's Name
Valley Palms
3 Location/Address where games will be conducted: City State ZIP Code
25 South 102nd Street #103 Mesa AZ 85208
4 Fill in the time on the days _ _.. qames will be la ed:
SUN MON TUE WED THUR FRI SAT
• a.m. Dam. • a.m. • a.m. • a.m. Dam. • a.m.
, Op m . , N p m ,630 ,t,„pm I1pfT1 1 .11Ipm , lipm . , •p.m.
5 Background investigations:
0 have 0 have not been conducted on all individuals listed in the Bingo License Application.
6 Recommendation for the application: 0 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) n (602) 716-7801
Previous 71-1002 (4/06)

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.
Licensees License Number
a lee„1 a 1 ins
Position (check th pproptiate boxes):
0,Manager 0 Supervisor 0 Proceed Coordinator 0 Assistant REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
88
If licensee is a qualified organization, complete the following section:
Member? Date Joined Organization
0 Yes III No 1 1
Officers? Officer Title
• Yes 111 No
Do you have an affidavit on file for any other licensee?
0 Yes 0 No If ''Yes", list license number(s):
)-0 U I S trillIS0/1 , the above-named affiant, under penalty of perjury, upon oath, depose
AFFIANTS NAME
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 have not and shall not receive any reward, compensation or recompense
for my participation in the conduct of bingo games except as provided for by law. 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
1402411
Date
Please mail to: Arizona Department of Revenue, PO Box 29019, Phoenix, AZ 86038-9019
211 (602) 716-7801
ADOR 10327(1114)
Previous 71-1003(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.
Licensee's Na I , License Number
1 Ile,/ Aims
rox mon (cneck me appr6priate boxes):
Manager 0 Supervisor 0 Proceed Coordinator rtg Assistant REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
If licensee is a qualified organization, complete the following section:
Member? Date Joined Organization
0 Yes •No 1 I
Officers? Officer Title
El Yes 1:3 No
Do you have an affidavit on file for any other licensee?
0 Yes U No If "Yes", list license number(s):
,arry 6c1, , the above-named affiant, under penalty of perjury, upon oath, depose
A HAM' NAME
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 have not and shall not receive any reward, compensation or recompense
for my participation in the conduct of bingo games except as provided for by law. 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.
/(7 /(7
2,6
Date
Please mail to: Arizona Department of Revenue, PO Box 29019, Phoenix, AZ 85038-9019
2T (602) 716-7801
ADOR 10327(1114)
Previous 71-1003(4/06)

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 V me i r) . License Number
altc ,/ illins
Position (check the dppropriate boxes):
I 0 Manager 0 Supervisor al Proceed Coordinator 0 Assistant REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
88
Affiant's Nar9 e
so . 71: 0) /16-Oriiimmi
Addre
City StataI I ZI
If licensee is a qualified organization, complete the following section:
Member? Date Joined Organization
Yes • No I I
Officers? Officer Title
Yes II No
Do you have an affidavit on file for any other licensee?
Yes • No If "Yes", list license number(s):
aty ty , the above-named affiant, under penalty of perjury, upon oath, depose
AFFIANIS Idiriscil NAME
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 have not and shall not receive any reward, compensation or recompense
for my participation in the conduct of bingo games except as provided for by law. 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.
/1/ ZO//7
Date
Please mail to: Arizona Department of Revenue, PO Box 29019, Phoenix, AZ 85038-9019
21 (602) 716-7801
ADOR 10327 (1/14)
Previous 71-1003 (4/06)

Arizona Form
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.
Licen,sep's Name License Number
ce s
Position (check the appropriate boxes):
0 Manager X Supervisor 0 Proceed Coordinator KlAssistant REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
88
Affiant's Name
If licensee is a qualified organization, complete the following section:
Member? Date Joined Organization
• Yes 0 No I I
Officers? Officer Title
• Yes No
Do you have an affidavit on file for any other licensee?
• Yes U No If "Yes", list license number s :
DO-L (Lk_ ss , the above-named affiant, under penalty of perjuiy, upon oath, depose
AFFIANT'S NAME
and say that T 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 have not and shall not receive any reward, compensation or recompense
for my participation in the conduct of bingo games except as provided for by law. 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.
Date
Please mail to: Arizona Department of Revenue, PO Box 29019, Phoenix, AZ 85038-9019
n (602) 716-7801
ADOR 10327 (1/14)
Previous 71-1003 (4/06)

Affidavit
This affid vit 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 ill be returned to you. All information is subject to verification. Disclosure of your Social Security Number (SSN) is voluntary. This information
may be ed to establish positive identification for purposes of criminal background checks pursuant to Arizona Revised Statutes § 5-404.
Licenseisrs Name License Number
Vct //e- y Fa- (rii S'
Position check the approptiate boxes):
0 Man I ger (*Supervisor 0 Proceed Coordinator 0 Assistan REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
ame
#45-sell ae, cYa rik-
rrPI1nne, Nn
If licentee is a qualified 6 anization, complete the following section:
Membe . Date Joined Organization
Ye El No I 1
Officer Officer Title
E3 Ye No
Do you frye an affidavit on file for any other licensee?
• Ye 0 No If "Yes", list license number(s):
gA 5 CL-' 7( /3 etelvv 7/7 , the above-named affiant, under penalty of peijury, upon oath, depose
and say that I will conduct AFRANTS or assist NAME in conducting all bingo games in compliance with the terms of the license, Arizona Revised
Sta tes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted of
an nisdemeanor involving moral turpitude or felony. I have not and shall not receive any reward, compensation or recompense
for ny participation in the conduct of bingo games except as provided for by law. I hereby swear or confirm that I have read
an understand the foregoing and verify that the information and statements made herein are true and correct to the best of my
kn v le dge.
Signature of Affiant
/(pO /77
Date
Please mail to: Arizona Department of Revenue, PO B x .29019, Phoenix, -AZ. 850389019
n (602) 716-7801
ADOR 10327 (1114)
Previa* 71-1003 (4106)

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. Disdesure 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.
Licen5e9's Nr9e License Number
i'a//e Fa S
Position (check the appropriate boxes):
Manager 14 Supervisor El Proceed Coordinator 13 Assistant REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
88
If licensee is a qualified organization, complete the following section:
Member? Date Joined Organization
0 Yes ci No I I
Officers? Officer Title
II Yes 0 No
Do you have an affidavit on file for any other licensee?
IIII Yes U No If "Yes", list license number s •
I /
//1 e r , the above-named affiant, under penalty of perjury, upon oath, depose
AFF1ANTS NAME
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 have not and shall not receive any reward, compensation or recompense
for my participation in the conduct of bingo games except as provided for by law. 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.
A if
Signe re Affian
0/
7
Date /21)/a2
Please mail to: Arizona Department of Revenue, PO Box 29019, Phoenix, AZ 85038-9019
tr (602) 716-7801
ADOR 10327(1/14)
Previous 71-1003(4/06)

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. Disdosure 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.
Liceosee's Name c. License Number
ot__At Le
Position (check the 4propriate boxes):
0 Manager gSupervisor 0 Proceed Coordinator 0 Assistant REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
88
If licensee is a qualified organization, complete the following section:
Member? Date Joined Organization
Dyes NI No
Officers? Officer Title
• Yes • No
Do you have an affidavit on file for any other licensee?
• Yes • No If "Yes", list license number(s):
V', e C) U2- 5 -e- , the above-named affiant, under penalty of perjury, upon oath, depose
AFFIANTS NAME
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 have not and shall not receive any reward, compensation or recompense
for my participation in the conduct of bingo games except as provided for by law. 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.
/7/Z07/ 7
Date
Please mail to Arizona Department of Revenue, PO Box 29019, Phoenix AZ 85038-9019
ix (602) 716-7801
ADOR 10327 (1114)
Previous 71-1003 (4/06)