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Arizona Department of Revenue * Bingo Section 41600 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. LICENSEE'S NAM LICENSE NUMBER Vall 0 “s/s dha [Usa Dizon teres Desert te ley POSITION boxes: Kerk Check the appropriate i (-] Supervisor [] Proceed Coordinator [1 Assistant AFFIANT'S S ™ wD ndrea 4 d Jenkins. Ain P ADDRESS by PN IN VT itd Ca het oe | & If licensee is a qualified organization, complete the following section: MEMBER? DATE JOINED ORGANIZATION CJ Yes (No [ee ee es ee OFFICERS? OFFICER TITLE OlYes [INo DO YOU HAVEJAN AFFIDAVIT ON FILE FOR ANY OTHER LICENSEE? ClYes “FRNo If “Yes”, list license number(s): f} le oly LLNS fn L. - the above named affiant, under penalty of , AFFIANT’S NAME perjury, upon oath, depose and say that | 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. LA4 SIGNATURE OF AFFIANT DATE ADOR 71-1003f (4/06)