DESERT VALLEY OASIS DBA MESA ARIZONA ACRES, LLC 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.
9 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.
1Applicant's Name „ ,
vailtv va.5)3 DBA kzoc Acve, LA-a- Falsification of information I
2a Mailing Address contained in this application 1
Cti-g e: 5-1-.) '2g13 constitutes a Class 6 felony
2b City State ZIP Code REVENUE USE ONLY. DO NOT MARK IN THIS r‘F; F
c.•Lo 88
3a Administrative Office Location
3b City State ZIP Code
4a Name of Contact Person j 4h Telpohnnp No
Al4reki._ € i`on5
4srmorilii 4c Fax No 81 PM 80 RCVD
03r/i
••I1
5 Class B and Class C license applicants only: If applying as a qualified organization, check one box to indicate the type o:
organization:
0 Charitable o Social 0 Religious 0 Veterans
ID 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:
fia Parent Name 6b Auxiliary Name
ar i
Address — Number and Street, Rural Rt., Apt. No. Address — Number and Street, Rural Rt., Apt. No. 0
City State ZIP Code City State ZIPCAde ,;', ,s7„
m — c
co
7 Class B and Class C license applicants only applying as a qualified organization, provide the date the organizatfeki wa›.
established in Arizona: i.,i , I „ i I
8 Class B and Class C license applicants only applying as a qualified organization, list the current officers of the o
fla Name 8b Name C-1 •• ..- --4 tfl ^ 7
--• 0
Title Title 6
_1
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 4
REVENUE USE ONLY. DO NOT MARK IN THIS AREA. 1
0 Approved 0 Disapproved n Class A License n Class B License ri 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)
De-se a Va4y bc,5,6 sbcv iqe-s(tAri-lovo, ,Ao_fe-e5 ) L APPLICATION FOR BINGO LICENSE
9 _ ' -
Checking Account Number Bank Name Bank Branch
10 Class B and Class C license applicants only: Bingo interest-bearing account information:
I_ II1LirrnL iBank Branch
11 Class B and Class C license applicants only: List all officers and/or supervisors authorized to sign checks from the accollris
listed above. If applying as a qualified organization, all supervisors must be • members ot me . 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.
12b Name
Title
Adchels s— Numb 1
and Street, Rural Rt., Apt. No. Address — Number and Street, Rural Rt., Apt. No.
City State ZIP Code ii
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.
Address — Number and Street, Rural Rt., Apt. No.
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
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
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 (1114) Arizona Form 833 Page 2 of 5
Previous 71-1010 (4/06)

Applicant's Name (as shown on page 1)
\I\ 1\04, t6 r2,0M, 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 n
member or new member of the applicant. Except for "Class A" licensees, each person must submit an affidavit.
16 Street address of the physical location where bingo will
q92, E
17 Indicate the time on each respective day that bingo will be played:
SUN MON TUE WED THUR FRI SAT
• • •
a.m. • a.m. ...1 a.m. a.m. III a.m. • a.m. Darn. .
• pm / IMp m , f ..°° IHp m , I • p m / IMp m I IMp ril I I p m 1
18 List dates of proposed game cancellation if any:
19 Indicate the type of premises where bingo will be played. Check one box:
a a Neither rent nor mortgage will be paid from bingo funds.
b (71 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 (71 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 171 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.
---I
Telephone Number (with area code) City State ZIP Code
Continued on page 4
ADOR 10334 (1/14) Arizona Form 833 Page 3 of E
Previous 71-1010 (4/06)

Applicant's Name (as shown on page 1)
QX264( Dobii3 Aa, 0 k eX6,51 APPUCATION FOR BINGO L Ot
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: per month
Payable to Address — Number and Street, Rural Rt., Apt. No.
Telephone number (with area code) City State ZIP Code
b Rent: sAl per CI month CI hour CI occasion
Payable to Address — Number and Street, Rural Rt., Apt. No.
Telephone number (with area code) City State ZIP Code
c Janitorial Services: $, /\,/,/ ft , per CI month CI hour CI occasion
Payable to Address — Number and Street, Rural Rt., Apt. No.
Telephone number (with area code) City State ZIP Code
Ai
d Accounting Services: $, //4 , per CI month CI hour CI occasion
Payable to Address — Number and Street, Rural Rt., Apt. No.
Telephone number (with area code) City State ZIP Code
e Security Services: , per CI month CI hour CI occasion
Payable to Address — Number and Street, Rural Rt., Apt. No.
Telephone number (with area code) City State ZIP Code
f Bingo Supplies:
Address — Number and Street, Rural Rt., Apt. No.
3/0 / Ac, F/001
City State ZIP Code
Okikr Og 7306
Line 21 continues on page 5
ADOR 10334 (1/14) Arizona Form 833 Page 4 of 5
Previous 71-1010 (4/06)

PAlicant's Narrm(as/shown on page 1)
Des e /LT 1/1//eX .P84 le54 4A/ezwd 11/2e5 APPLICATION FOR BINGO LICENSE
21 Expected Bingo Expenses, continued...
g Maximum prize payout per occasion - $ APO ,. Attach game schedule that lists individual prize amounts.
Paid to j . Address - Number and Street, Rural Rt., Apt. No.
Z2.5 41 9 te22 /E,74//4) si oaf
Telephone number Jth area code City State ZIP Code
ø54 ,4___ 8679.0 7-
h Utility Expenses:
Electric (payable to) Address - Number and Street, Rural Rt., Apt. No.
AVA
Account Number Monthly Amount City State ZIP Code
$
Gas (payable to) , Address - Number and Street, Rural Rt., Apt. No.
A)/4
Account Number Monthly Amount City State ZIP Code
$
Water (payable to) Address - Number and Street, Rural Rt., Apt, No.
A-)74
Account Number Monthly Amount City State ZIP Code
$
Trash Removal (paya le 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:
014/Z7e7—05/144-11-4--1 , 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.
gel
'9*
" r•A-,5)2 Ati-A)
A VW ATURE DATE TITLE
Please mail to: Arizona Department of Revenue, PO Box 29019, Phoenix, AZ 85038-9019
tt (602) 716-7801
ADOR 10334 (1/14) Arizona Form 833 Page 5015
Previous 71-1010 (4/06)

Arizona Department of Revenue • Bingo Section
1600 West Monroe, Phoenix, AZ 85007 • (602) 716-7801
AFFIDAVIT
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 is voluntary. This information may be used to establish positivi-)
identification for purposes of criminal background checks pursuant to Arizona Revised Statutes, §5-404.
Please type or print in black ink.
We7eS)EliS N\T(4421 Do 5 Ix, volt k6,Dija, }vitro LICENSE NUMBEF
POSITION
Check the appropriate boxes: 0 Manager 0 Supervisor gi Proceed Coordinator 0 Assistant
AFEJANT'S NAM SOCIAL SECURITY NO
DATE OF BIRTH
ri TV 710 (' t1-
HOME PHONE Na (with area code) , egE 1 NO. (with area code)
WORK1 n
If licensee is a qualified organization, complete the following section:
MEMBER? DATE JOINED ORGANIZATION
0 Yes 0 No II I t
OFFICERS? OFFICER TITLE
0 Yes 0 No
DO YOU HAVE AN AFFIDAVIT ON ALE FOR ANY OTHER LICENSEE?
0 Yes 0 No If "Yes", list license number(s).
I, _OP/Aii/A& oPlya,444/ 6 , the above named affiant, under penalty ci
AFRANTS NAME
perjurY, upon oab, depose and say that 1 wiil 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 ieensinit
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 connrm
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.
/ //..?//46
DATE

Arizona Department of Revenue • Bingo Section
1600 West Monroe, Phoenix, AZ 85007 • (602) 716-7801
AFFIDAVIT
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 is voluntary. This information may be used to establish positive
identification for purposes of criminal background checks pursuant to Arizona Revised Statutes, §5-404.
Please type or print in black ink.
LICENSEES NAM y , LICENSE NUMBER
Tf2.6C,f4' \ialkstki 0 0'13 Mt- P\\21-2,6 114, /-61-
POSITION
Check the appropriate boxes: Manager 0 Supervisor 0 Proceed Coordinator 0 Assistant
AFFIAlp§ tlAME 77.e SOCIAL SECURITY NO.
C / -e-_5 773244
ADDDQQ
CITY STATE
WORK PHONE NO. ( ,with area code)
/0 7-1--
If licensee is a qualified organization, complete the following section:
MEMBER? DATE JOINED ORGANIZATION
• Yes 0 No
OFFICERS? OFFICER TITLE
El Yes • No
DO YOU HAVE AN AFFIDAVIT ON FILE FOR ANY OTHER LICENSEE?
• Yes e No If "Yes", list license number(s):
I, Cli4E , the above named affiant, under penalty of
AFFI TS NAME
peijury, upon oath, 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 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
ADOR 71-1003f (4/06)

Arizona Form
Affidavit
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.
[Leer" irrni • Kt*Lovdt License Number
,\)1),- ROL Kt-A- 1,Lb
Position (check the appropriate boxes):
0 Manager El Supervisor El Proceed Coordinator 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 • No I I
Officers? Officer Title
El Yes • No
Do you have an affidavit on file for any other licensee?
El Yes • No If "Yes", list license number(s):
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 o f
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.
/3
Ple-ase mail o: Arizona Department of Revenue, PO Box 29019, Phoenix, AZ 85038-9019
II (602) 716-7801
ADOR 10327 (1/14)
Previous 71-1003 (4/06)