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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 Falsification of information Arizona Acres (aka) Desert Valley Oasis contained in this application 2a Mailing Address constitutes a Class 6 felony. 9421 E. Main st B-38 2b City State ZIP Code REVENUE USE ONLY. DO NOT MARK IN THIS AREA. Mesa Az 85207 88 3a Administrative Office Location 3b City State ZIP Code 4a Name of Contact Person 4b Telephone No. Bernard (Bernie) Alt 4c E-mail Address • c ax 1 0. 81 PM 80 RCVD 5 Class B and Class C license applicants only: If applying as a qualified organization, check one box to indicate the type of organization: El Charitable 0 Social O Religious 0 Veterans 0 Fraternal 0 Volunteer Fire Department O 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: I,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 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 Continued on page 2 REVENUE USE ONLY. DO NOT MARK IN THIS AREA. o o o n Approved 71 Disapproved Class A License Class B License Class C License Reviewer's Name (please print) Date License Number Effective Date Expiration Date ADOR 10334 (1/14) Previous 71-1010 (4/06) Applicant's Name (as shown on page 1) Arizona Acres (aka) Desert Valley Oasis APPLICATION FOR BINGO LICENSE 9 . . Checking Account Number Bank Name Bank Branch 10 • .. 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 11b 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. 12a Name 12b Name Charles (Chuck) Smalley Bernard Alt Title Title Manager Assist Manager 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. Dorthy (Dotti) Warner Title City State ZIP Code Proceeds Coordinator 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 Mischelle Felbab Title Title Supervisor 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 Supervisor 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) Arizona Acres (aka) Desert Valley Oasis 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 15c Name 15d Name 15e Name 15f Name 15g Name 15h Name 16 Street address of the physical location where bingo will be played: 9421 E Main St Mesa Az 85207 17 SUN MON TUE WED THUR FRI SAT oa.m. • a.m. • a.m. Ram. • a.m. • a.m. Dam. Rpm , 7:00 , I:(p m , , Rpm i iElp m i i Rpm tip 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 1St Neither rent nor mortgage will be paid from bingo funds. b J 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 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 o Owned jointly with other organization. Attach cony 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 (1114) Arizona Form 833 Page 3 of 5 Previous 71-1010 (4/06) Applicant's Name (as shown on page 1) Arizona Acres (aka) Desert Valley Oasis 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 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: saao , per month Payable to Address — Number and Street, Rural Rt., Apt. No. Telephone number (with area code) City State ZIP Code b Rent: $, 0.00 , per 0 month El 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: $J0.00 , per month 0 hour 0 occasion Payable to Address — Number and Street, Rural Rt. Apt. No. Telephone number (with area code) City State ZIP Code d Accounting Services: $, 0.00 , 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 e Security Services: $ 0.00 per CI 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 Bingo Supplies: $.400.00 , Per year Payable to Address — Number and Street, Rural Rt., Apt. No. Cactus Bingo 3210 Roeser Rd Suite 15 Telephone number (with area code) City State ZIP Code (602) 268-2848 Phoenix Az 85040 Line 21 continues on page 5 4 ADOR 10334 (1/14) Arizona Form 833 Page 4 o15 Previous 71-1010 (4/06) Applicant's Name (as shown on page 1) Arizona Acres (aka) Desert Valley Oasis APPLICATION FOR BINGO LICENSE 21 Expected Bingo Expenses, continued... g Maximum prize payout per occasion: $150.00 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 $ 0.00 Gas (payable to) Address — Number and Street, Rural Rt., Apt. No. Account Number Monthly Amount City State ZIP Code $ 0.00 Water (payable to) Address — Number and Street, Rural Rt., Apt. No. Account Number Monthly Amount City State ZIP Code $ 0.00 Trash Removal (payable to) Address — Number and Street, Rural Rt., Apt. No. Account Number Monthly Amount City State ZIP Code $ 0.00 22 Briefly state the specific p rojected use of net procee s from games of bingo: , taletatZ3e, c . , Ai<, i ii i r /6 7LA-r2 a I, Charles (Chuck) Smalley , 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. /-0,?)/7Z.Manager DATE TITLE Please mail to: Arizona Department of Revenue, PO Box 29019, Phoenix, AZ 85038-9019 n (602) 716-7801 ADOR 10334 (1114) 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. Date License Number tEl New Application (71 Change of Location From (Name of local governing body) Address (number and street, PO Box) City State ZIP Code Phone No. (with area code) 1 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: o Application for a bingo license by the following applicant. 0 Application for a bingo license location transfer. 2 Applicant's Name Arizona Acres (aka) Desert Valley Oasis 3 Location/Address where games will be conducted: City State ZIP Code 9421 E. Main st Mesa Az 85207 4 Fill in the time on the days games will be played: SUN MON TUE WED THUR FRI SAT • a.m. Dam. • a.m. • a.m. U a.m. Dam. • a.m. , • p.m. , , Rpm. , 7:00 I .1 p.m. I I p.m. . p.m. I . p.m , , • p.m. 5 Background investigations: (El 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. Licensee's Name License Number Arizona Acres (aka) Desert Valley Oasis Position (check the appropriate boxes): [8] Manager 0 Supervisor 0 Proceed Coordinator 0 Assistant REVENUE USE ONLY. DO NOT MARK IN THIS AREA. 88 Affiant's Name Charles (Chuck) Smalley Social Security Number Date of Birth Address City State ZIP Code Home Phone No. (with area code) I Workone N o. (with area co e If licensee is a qualified organization, complete the following section: Member? Date Joined Organization • Yes • No I I Officers? Officer Title • Yes •No Do you have an affidavit on file for any other licensee? III Yes • No If "Yes", list license number(s): 1, Charles (Chuck) Smalley , 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. ‘--1-0,1 Date Please mail to: Arizona Department of Revenue, PO Box 29019, Phoenix, AZ 85038-9019 if (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 ' Name License Number del zon)/4 .4i,e/4,) :1)e-6e/el /41A a45-1:9 Position (check the appropriate boxes): LA Manager EI Supervisor 0 Proceed Coordinator VIAssistant REVENUE USE ONLY. DO NOT MARK IN THIS AREA. 88 Affiant's Name Bernard ( Bernie) Alt Date of Birth Address If licensee is a qualified organization, complete the following section: Member? Date Joined Organization • Yes • No I I Officers? Officer Title • Yes • No Do you have an affidavit on file for any other licensee? El Yes • No If "Yes", list license number(s): I, Bernard ( Bernie) Alt , the above-named affiant, under penalty of pedury, upon oath, depose AFFIANT'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 true and correct to the best of my knowledge. ‘-/57-,QD tr?- 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 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 Arizona Acres (aka) Desert Valley Oasis Position (check the appropriate boxes): 0 Manager 0 Supervisor S Proceed Coordinator 0 Assistant REVENUE USE ONLY. DO NOT MARK IN THIS AREA. 88 Affiant's Name Dorothy (Dotti) Warner If licensee is a qualified organization, complete the following section: Member? Date Joined Organization • Yes • No I I Officers? Officer Title • Yes M No Do you have an affidavit on file for any other licensee? 121 Yes II No If "Yes", list license number(s): I, Dorothy (Dotti) Warner , the above-named affiant, under penalty of perjury, upon oath, depose AFFIANT'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 true and correct to the best of my knowledge. Pi-gol 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 Name License Number ../Ze.5 (AKIO De 6 aez y Position (check the appropriate boxes): 0 Manager Supervisor 0 Proceed Coordinator 0 Assistant REVENUE USE ONLY. DO NOT MARK IN THIS AREA. 88 Affiant's Name Mischelle Felbab Sol Date of Birth Ad8IT ity State ZIP Code Home Phone No. (with area code) Work Phone No. (with area code) If licensee is a qualified organization, complete the following section: Member? Date Joined Organization 0 Yes • No I I Officers? Officer Title 0 Yes • No Do you have an affidavit on file for any other licensee? 0 Yes • No If "Yes", list license number(s): I, Mischelle Felbab , the above-named affiant, under penalty of perjury, upon oath, depose AFFIANT'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 tr .nd correct to the best of my knowledge. Date Please mail to: Arizona Department of Revenue, PO Box 29019, Phoenix, AZ 85038-9019 fl (602) 716-7801 ADOR 10327 (1/14) Previous 71-1003 (4/06)