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LLL ' 0 N1 VLHL L AO IWJ 1311!34 Arizona Form 833 Application for Bingo License • Type or print in black Ink and complete all information requed on this form. If you do net, your areilartbn will be returned. All informaiiOn is subject to verification. If you need more soacE, attach additional sheers. . • AU bingo licenses aspire one year from the date of issue lb continue CondutUng binge gOini, You must Mew your license prior to the mrpiration date. APPlifont's NAmo 5 C ass B and class C license applicants only: If applying as a qualified organization, check one box to indicate the type of ofganization: Charitable Social' 13 Religious 0 veterans Fraternal 13 Volunteer Fire Department EI Homeowners Association El NonprOfitArribulande Service 8 doss Rand Class C license applicants only applying as a qualified organization, provide parent or auxiliary information: Parent Name r6bAuxiliery Name ddress - Number and Street, Rural ft. Apt Na. Address - Number and Street, Ruraik.. Apt No State ZIP Code 71P Code i I s lass B and Class C license applicants only applying as a qualified organization, provide the date the organization WO8 tat:Wahl:4 in Arizona: iM,Mi fp , ',i 1 `,' . • 8 lass B and Class C license applicants only applying as a qualified organization, list the current officers of the organization: la Name ab Name ntie Address- Number and Street Aural Rt, Apt No. Address- Number and Street, Rural Rt., Apt No. State ZIP Code City State ZIP Code 18c NOrrie 8d Name Title Address -Number and Street Rural Rt., Apt. No. Address -Number and Street. Rural Rt,APt No. city State ZIP Code fty State ZIP Code Continued on page 2+ , • ., , :.ii--ea,': ,,:, .*?,4:400M111:.i.Invii:Wig : :11 -1=111•., ' : W • f•• ‘i 'II ;.•, ',Ififygia6'..E:A E iproved 0 Disapproved 0 Class A License 0 Class B License 0 Class C License - erS Nama (please print) Date Memo Number Sifeetive Date • Explratkm Elate +,.,,E. • 925,6ramswoLt,,,yarigganivamprizmwww...,,,,,isoftweitww,te,,,,,,,TywantgaxeSrAfteamallatitaltraYONWAT EIV IVIMERAIMMUIRttigiellaMiet Arialb334 (1114) Pre a 71-1010 (4108) LI a ' 0 N WV/I:ll /06 '[' ,\ 0 1N attiLL pan!apq 9 CIiIu B and Class C licenac aovlivants o : I3lnno checkIr account Information: Bank Branch : rnqActoUnt Number Bank Name 10 C a B and Class C Ikons, a Cants rungigusainaggg account information: Bank Branch ount Number Bank Name 11 C etd ea B and Class C license applicants only: List all offhiers andlor supervisors authorized to sign checks from the accounts 6 above, If applying as a qualified organ ftation , all aup must be members of the applicant ' S tato ZIP Cod 12 Litt the name(s) of the one or two persons who will serve ais managers. if applying as a qualified organization. these Persons t be members cite applicant EWA pefS011 Must StIbtlat an affidavit '101S TANTIPson 13 List the name of the one person designated as proceeds coordinator. If applying as s qualified organization, this person must be officer or director ingi a member of the applicani! Eaqh person must submit an affidavit Sohtt bra 711tI f!nrip 14 .11ist the name(s) of the person(s) who will serve as superviot : if applying as a qualified organization, each person must be a of the applicant Lech parson must submit an affiliate 0334 (1114) Antony F00» 833 Page 2 Of 5 71-1010 (4108) LL •°N1 AVCI:11 AO 1tJjP'A!34 15 Lire name(s) of the penson(s) who will serve as assisiants; If applying as a qualified organization, each person meet be a m bar or new member of the applicant except for '161assfA" licensees, each person must submit an affidavit. iS.Nome i5b Name 15,r Name 15d Name , • 15. Name 15f Name I 'Mr Name 1h Name 16 S ti t address e of the physical location where bingo will 4o PI adj AfaJils 17 in [Gate the time on each that bi will be FRI SAT Dam. Dam Elam- m . Ilan 18 U dates of proposed game cancellation If any: 19 I ri bate the type of premises where bingo will be played. C/leck one box a X Neither rant nor mortgage will be paid from binge furt4. b ID Rented or leased. Atteoh rental affidavit and copy of •-entaf agreement. Landlord's Name. Address - Number end Str4et, Rural Rt., Apt. No. Telephone Number (with area code II11.11.1I10 State ZIP Code c I 0 Owned solely by the organization_ Attach cooy of moirtga' ge deed &trust purchase agreement, escrow agreement, or other related document . Holder of Mortgage f Address - Number sod Street, Rural Rt., Apt No. elephorte Number (with area code) City State ZIP Code 4-.4- Owned lointty with other organization. Attach cUpv Emo,tgpga,. dead of trust, purchase agreement, esCIOVI agreement or other related document 1) Holder of Mortgage Address- Number 'end Street. Rural Rt., Apt No Telephone Number (with area code) City - State ZIP Code Co-Owrier Flakier; Address- Number and Sheet, Rural Rt., ipt. No_ Telephone Number (With area axle) City . State ZIP Code 3) Co-Owner older Address-' Number and Skeet. Rural rd., Apt No. • 1 'Telephone Number (with area code) City • state ZIP gode Cordinuedi on pew . 4 + ADOR 94 (1n4) Artiona. Form 833 Poe 3 of 5 Pubv 711)10 14/06) 20 Lie bingo licensees who are or will be conducting bingo in the same pretytives as you end those licensees located within 1,000 fee of your prentlees: illimill.W 2b Name • . . reee - Number and Sheet, Rural Rt.. APt- Address Number and Street, Rural Rt., Apt. No, i State ZIP Code City Saito ZIP Code I I 21 ed bingo expenses: a Mortgage; Per month rP-iziyab to Addresa - Number and Street. Rural Rt. Nat No, Telephone number (with area code) Stale AP Cod I, Rent per CI rriolitti 0 hour ei occasion Payable to Address - Number and Street, Rural Rt., Apt, No. Telephone number (with mei code) City Slate ZIP Code 0 Janitorial Services: rt1rrtonit 0 hour 171 occasion Payable to Address- Number and Street Rural Rt., Apt No -telephone number (with area code) City state ZIP Code d Accounting Services: per 0 rrionli 0 hour 0 =Won Payable to —Wnber---N— Addre and beet, Rural Apt No. Telephone number (With area code) State ZIP ?ode . 1 4 Security Services: Adik] Per 0, month Cl hour 0 occasion IPaYable to rAddress - Number and Stioet, Runt Rt, Apt No. Telephone number (with area code) State ZIPCod ' e Bingo Supplies: St...7.5-a) Paysbie to Address - Number and - ,.1‘: : Rum! Rt., Apt No. . C4 S AI ., ,.. I rO e--S' S : te ZIP POde Telepti a number area code) 1 Line 21 continue on pogo 5 -) ADOR 10334(1114) Artina Foal en Page 4 of Pnavio a 71-101.0 (4106) ILIE 'ON NVCHL 'HAO n, !1 PA! 93 q 21 x4ected )31ngo Expenses, continued_ 42 0_ ti mum Prize payout per occasion: s O8. .J Attach game schedule that lists inctivklual prize RITKAUrrt& Paid to • : Address— Numbers Mutat Rural Rt., Apt, NO. • . 1 Telephone number (with wee code) ; City State ZIP Coda , h IUtilfty Expenses: Electric (payable to) , Address — Number and Street, Rural Rt., Apt No. Account Number Monthly Amount City Stale ZIP Code Gas (Payable lb) , Address — NUMbar and Street Runal Rt_,Apt No. • ; lq , Account Number City State :4 PCode Wafer (payable to) , ; Address— Number end Street Rural RI, Apt Na. 'Account Number Monthly Amount . 73P code $ ---- Trash kTh mov it ayable ' Address— Number and Street, Rural Ftt., Apt. Ns. . , N . . AccountNurriber Monthly Amount City State ZIP Coda $ • • 22 40y efty state the apeoik proiected use of net proceeds*orn . games of bingo: Arapxt aell:DX4.4J puk ;...•III1! 141.117S under penalty of perjury and upon pas*, declare that I am duly authorized to sign and f u this application. I y swear or c,onfinn that have read the foregoing application and loww the contents thereof and that all infatuation provided has been il1y, accurettly, and trethfully compltrited to the best cif my knowledge. .( ef 41 ARAL ANTS SIGNA - 1 ATE OPE '10041k04i6OW 'iltliettftkitr4Whil ft (602) 716-7801 ADOR 11)34 (1114) Arizona Form .; Pato 6 cite Printout' 71-1010 (4/00) 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. O Local Governing Body: Complete and return with license package to the Department of Revenue Bingo Section. Date License Number X New Application 71 Change of Location From (Name of local governing body) REVENUE USE ONLY. DO NOT MARK IN THIS AREA. Address (number and street, PO Box) 88 City State ZIP Code Phone No. (with area code) 81 PM 80 RCVD 1 This is to certify that on i I I a 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. o 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 102ni_ Street #103 Mesa AZ 85208 4 Fill in the time on the days games will be played: SUN MON TUE WED THUR FRI SAT 0a.m. Dam. • a.m. Ela.m. Oa.m. • a.m. • a.m. • pm ,IIIIIpm , 6:30 ,opm . • p m , , Op m i Op m , , • 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 (1/14) n (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. Tir7 License Number Va . )11.5 Position (check th ppropriate 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 II No I I Officers? Officer Title 0 Yes II No Do you have an affidavit on file for any other licensee? II Yes 0 No If "Yee, list license number(s): .Tt NAI2,2 0 T , the above-named affiant, under penalty of petjury, upon oath, depose AFFIA NA 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 Date Please mail to: Arizona Department of Revenue, PO Box 29019, Phoenix, AZ 85038-9019 (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 Na License Number al(el Pair" Po ition (check the appr priate boxes): Manager El Supervisor 0 Proceed Coordinator rog Assistant REVENUE USE ONLY. DO NOT MARK IN THIS AREA. 1411111111111I1111711111 . est:. 11E1111 r"11.71 1"411111111 Work Phone No. (with area code) ir""‘"Wl — - If licensee is a qualified organization, complete the following section: Member? Date Joined Organization 1:1 Yes X No I I Officers? Officer Title 0 Yes 0 No Do you have an affidavit on file for any other licensee? 0 Yes • No If "Yes", list license number(s): 1, Larry Vi ocf. , the above-named afflant, under penalty of perjury, upon oath, depose AFFIANT 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. /(7z6/(7 Date Please mail to: Arizona Department of Revenue, PO Box 29019, Phoenix, AZ 85038-9019 IT (602) 716-7801 ADOR 10327 (1/14) 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 N me, () , License Number a I Ic q rally6 Position (check the aippropriate boxes): 0 Manager 0 Supervisor IA 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 • Yes SNo I I Officers? Officer Title Yes • No Do you have an affidavit on file for any other licensee? 0 Yes 0 No If "Yes", list license number(s): 1, y J-6)11 riSori , the above-named affiant, under penalty of perjury, upon oath, depose AFNANT'S 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 tnie and correct to the best of my knowledge, /11 2,0/77 Date Please mail to: Arizona Department of Revenue, PO Box 29019, Phoenix, AZ 85038-9019 n (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. Licerpe's Name License Number V eft rvk s Position (check the appropriate boxes): 0 Manager ' Supervisor 0 Proceed Coordinator If licensee is a qualified organization, complete the following section: Member? Date Joined Organization El Yes 0 No I I Officers? Officer Title • Yes 0 No Do you have an affidavit on file for any other licensee? • Yes 0 No If "Yes", list license number(s): Do-L P , 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. /1 /20/7F Date ( Please mail to: Arizona Department of Revenue, PO Box 29019, Phoenix, AZ 85038-9019 2? (602) 716-7801 ADOR 10327 (1114) Previous 71-1003 (4/06) Arizona Form Affidavit 830 This affli tit 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. Licenses Name License Number V et 1 le—y II a_ / rii s' Position check the approptiate boxes): 0 Man I ger orSupervisor 0 Proceed Coordinator 0 Assistant REVENUE USE ONLY. Do NOT MARK IN THIS AREA. 88 ame Nots-se Bo isn e Number I Date of Birth If licentee is a qualified organization, complete the following section: Membe . Date Joined Organization El Ye El No 1 1 Officer Officer Title El Ye No Do you aye an affidavit on file for any other licensee? Ye 0 No If "Yes", list license number(s): 1, I 5 / 3&, vv , the above-named affiant, under penalty of perjury, upon oath, depose and say that I will conduct AFFIANIS or assist NAME in conducting all bingo games in compliance with the terms of the license, Arizona Revised Sta4àltes, Title 5, Chapter 4, and the rules of the licensing authority. I am of good moral character and have never been convicted of anyinisdemeanor involving moral turpitude or felony. I have not and shall not receive any reward, compensation or recompense for y 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 lcrijsvledge. Signature of Affiant //pc) /77 Date Please mail to: Arizona Department of Revenue, PO Box 29019, Phoenix, AZ 85038-9019 TT (602) 716-7801 ADOR 110327 (1114) Previott 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. Licen,9's Nfr License Number //e Li crPa Position (check the Oppropriate boxes): 0 Manager 1$ Supervisor 0 Proceed Coordinator El Assistant REVENUE USE ONLY. DO NOT MARK IN THIS AREA. If licensee is a qualified organization, complete the following section: Member? Date Joined Organization CI Yes 1111 No ri II . Officers? Officer Title 0 Yes • No Do you have an affidavit on file for any other licensee? 0 Yes 0 No If 'Yes", list license number(s): 7 A/24/1 / 7/1 161 ef , the above-named affiant, under penalty of perjury, upon oath, depose AFHANTS 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. Signe re Affiant Date Please mail to: Arizona Department of Revenue, PO Box 29019, Phoenix AZ 85038-9019 IT (602) 716-7801 ADOR 10327(1/14) Previous 71-1003(4/06) Arizona Form Affidavit m ao 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. 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. Lice see'sN me 11 License Number sP, l\k_ Position (check the apropriate boxes): 1:1 Manager 'Supervisor 0 Proceed Coordinator 1:1 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 III Yes III No i I Officers? Officer Title 0 Yes 0 No Do you have an affidavit on file for any other licensee? ID Yes U No If "Yes", list license number(s): 1, ict. e t)c_p_ , the above-named affiant, under penally of perjury, upon oath, depose AFFrorrshme 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. Date Please mail to: Arizona Deparbnent of Revenue, PO Box 29019, Phoenix, AZ 85038-9019 TI" (602) 716-7801 ADOR 10327(1(14) Previous 71-1003 (4/06)