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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. • 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 DREAMLAND VILLA COMMUNITY CLUB contained in this application 2a Mailing Address constitutes a Class 6 felony. 320 N. 55th Place 2bCity State ZIP Code REVENUE USE ONLY. DO NOT MARK IN THIS AREA. MESA AZ 8520 88 3a Administrative Office Location 320 N 55th Place 3b City State ZIP Code MESA AZ 85205 4a Name of Contact Person 4bTelohone No. Jiniaeamandel 4c E-mail Address 4c Fax No. 81 PM 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: O Charitable (El Social O Religious 0 Veterans o Fraternal 0 Volunteer Fire Department O Homeowners Association 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 DREAMLAND VILLA COMMUNITY CLUB DREAMLAND VILLA COMMUNITY CLUB Address - Number and Street, Rural Rt., Apt. No. Address - Number and Street, Rural Rt., Apt. No. 320 N. 55th Place 320 N. 55th Place City State ZIP Code City State ZIP Code MESA AZ 85205 MESA AZ 85205 7 Class B and Class C license applicants only applying as a qualified organization, provide the date the organization was established in Arizona: 10, 110, 111,9,5,9j 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 Jim Seamandel . I lennings Title Title Mana er President of the Bingo Board P r in r 1 2 - Address - Number and Street R Au. No. Address - Number and Street, Rural Rt., Apt. No. 8e Name 8d Name Carol Cooper Ma Seamandei Title Title Bin .o Chair erson,Secretarv of the Bingo Board Bingo Board Member Address - Number and Street, Rural Rt., Apt. No. Address - Number and Street, Rural Rt., Apt. No. Continued on page 2 + REVENUE USE ONLY. DO NOT MARK IN THIS AREA. ['Approved ['Disapproved ['Class A License o Class B License o Class C License Reviewer's Name (please print) Date License Number Effective Date !Expiration Date Applicant's Name (as shown on page 1) DREAMLAND VILLA COMMUNITY CLUB APPLICATION FOR BINGO LICENSE 9 Class B and Class C license applicants only: Bingo checkina account information: Checking Account Number Bank Name Bank Branch National Bank of Arizona 5555 E Main St. Mesa. AZ 85205 10 Class B and Class C license applicants only: Bingo interest-bearinq account information: Account Number Bank Name Bank Branch 11 Class B and Class C license applicants only List all officers andior 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 11 b Name Jim Seamandel Ward Jennings Title Title Manager Proceeds Coordinator Address — Number and Street, Rural Rt., Apt. No. Address — Number and Street, Rural Rt., Apt. No. 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 Carol Cooper 3inao Chairperson Fkaaress — Number ann Rural Rt Ant NW Address — Number and Street, Rural Rt., Apt. No. 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 aug a member of the applicant. Each person must submit an affidavit. Name l Address — Number and Street, Rural Rt., Apt. No. Ward Jennings Title Proceeds Coordinator. DVCC Board Member 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 Jim Seamandel Ward Jennings Title Title Manager Proceeds Coordinator Address — Number and Street, Rural Rt., Apt. No. Address — Number and Street, Rural Rt., Apt. No. 14c Name 14d Name Carol Cooper Title Title Bingo Chairperson Address — Number and Street Rural Rt. Aet. No. Address — Number and Street, Rural Rt., Apt. No. City State ZIP Code Applicant's Name (as shown on page 1) DREAMLAND VILLA COMMUNITY CLUB 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 CVn Mundav Mary Seamandel 16c Name 15d Name Earl Munday Jim Doherty 16e Name 15f Name 15g Name 15b Name 16 Street address of the physical location where bingo will be played: 6159 E. University Dr.. Mesa. AZ 85205 17 Indicate the time on each respective day that bingo will be played: SUN MON TUE WED THUR FRI SAT Dam. Dam. Dam. Dam. Dam. Da.m. Dam. 1 10p.m. Ll -3 , IQ pm 1 417P m , Op m , . • p m lipp m . tlpm 18 List dates of proposed game cancellation if any N/A 19 Indicate the type of premises where bingo will be played. Check one box: El Neither rent nor mortgage will be paid from bingo funds. b CI 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 o 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. N (4 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. iN1 IA 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 Applicant's Name (as shown on page 1) DREAMLAND VILLA COMMUNITY CLUB 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 oremises: 20a Name 20b Name N/A N/A 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 Mortoaoe: $1 0.00 , 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 171 month 171 hour J occasion Payable to Address — Number and Street, Rural Rt., Apt. No. Telephone number (with area code) City State ZIP Code c Janitorial Services: $ 1 0 00 , per 1 month J hour J occasion Payable to Address — Number and Street, Rural Rt., Apt. No. Telephone number (with area code) City State ZIP Code d Accounting Services: $,O_QQ , per 171 month 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: $,CLOC) per 11 month hour occasion Payable to Address — Number and Street, Rural Rt., Apt. No. Telephone number (with area code) City State ZIP Code f Bingo Supplies: $, 250.00 , per month Payable to Address — Number and Street, Rural Rt., Apt. No. Cactus Bingo Supply 3210 E Roeser Rd.. Suite #15 Telephone number (with area code) City State ZIP Code (602) 268-2848 Phoenix AZ 8504030 Line 21 continues on page 5 Applicant's Name (as shown on page 1) DREAMLAND VILLA COMMUNITY CLUB APPLICATION FOR BINGO LICENSE 21 Expected Bingo Expenses, continued... g Maximum prize payout per occasion: aa000.00 ,. Attach game schedule that lists individual prize amounts. Paid to Address — Number and Street, Rural Rt., Apt. No. Winners at Location 6159 E. Universtity Telephone number (with area code) City State ZIP Code (262'1853-7725 Mesa AZ 85205 h Utility Expenses: Electric (payable to) Address — Number and Street, Rural Rt., Apt. No. NA Account Number Monthly Amount City State ZIP Code $ Gas (payable to) Address — Number and Street, Rural Rt., Apt. No. NA Account Number Monthly Amount City State ZIP Code $ Water (payable to) Address — Number and Street, Rural RL, Apt. No. NA Account Number Monthly Amount City State ZIP Code $ Trash Removal (payable to) Address — Number and Street, Rural Rt., Apt. No. NA Account Number Monthly Amount City State ZIP Code $ 22 Briefly state the specific projected use of net proceeds from games of bingo: Financial support of facilities, activities, and entertainment programs at Farnsworth Hall, one of two community centers in Dreamland Villa. I, Jim Seamandel , 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. YvviLiv (e) Manager APPUCANTS SIGNATURE DATE TITLE Please mail to: Arizona Department of Revenue, PO Box 29019, Phoenix, AZ 85038-9019 n (602) 716-7801 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 n New Application Change of Location June 3. 2015 07-336-B 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) 1 This is to certify that on 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. ID Application for a bingo license location transfer. 2 Applicant's Name DREAMLAND VILLA COMMUNITY CLUB 3 Location/Address where games will be conducted: City State ZIP Code 6159 E University Dr Mesa - 85205 4 Fill in the time on the days games will be played: SUN MON TUE WED THUR FRI SAT Ela.m. Dam. Dan. N a.m. Dam. • a.m. • a.m. i 'Ppm .1-3 'Op m . I OP m 1 , • pm , Op m , I:IP m , -Ulm. 5 Background investigations: 12 have El have not been conducted on all individuals listed in the Bingo License Application. 6 Recommendation for the application: El Approved El 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) Tr (602) 716-7801 71_1nn9 minm Affidavit Bingo Thia affidavit mugt bo complotod oath 'Argon who wighog to agglat in tho conduct of any gam@ of bingo. If any information la blank or incorract, tho affidavit will ho roturnod to you, All information la gubioct to vorification. Digcloguro of your Social Smutty Numbor (55N) la voluntary, Thig Information mgy ho wood to oatabligh 13@§itiV@ IhiltifiggiOrl for ourp000g of criminal background chock§ prouant to Arizona Roviood Statutog 0.4ffit, LINN@ NUMW 4° Li. k C lu Poollion (ohook tho aopropriato oxog)t MAF1AOPF II§LIIMVi§Or ElProcood Coordinator rn Acoictant ,mvviiNNtur 1414§V iiNNLLYY NNOOTT MMAAIN IN T111§ AIWA, ei Oitv ltntn ZIP Co& Horn- Work hono No (with grog gado If finnan@ in n nualifind oranntion, enniploto thn following unotIon; MOffitit i? doinod Organization Yo § El No 1.241 aola, offipro ()Moor Milo 11 y 111 No no you I1§Vo on affidavit on filo for any othor li@f411N067 11 VP§ No If "Yoe. II§t lloon§o humbug 1, U. m S , the abovo-mtmod nffinnti undo! pnintlty of pnrjury, upon with, ilnpotin and gay thnt I will eonduct or whit in condunting nil bingo g0111P§ in Pompilanco with the intim of ih lienn§e Arizona It nvinnil litututeti,Tub hopter 41 nod the roloo orthe lio0o§loti nathority, I ant ofgood tnorgi olutritotor nod lmvo NM boon conviotod of any mitiduntotitior invoiving mond turpitude or folotly, Ititivg not nod tihnll not recnivn tiny rowurtl, compongation or r000nmonao for my putioipation bu tho conduot of bingo puma oNoopt na provictod tbr by low I horoby filiNtIr or oonfirm Mat I Imo rood and midontand tito foregoing Lind verify thin thn infortnittion tind ntoteninntn Mak Iwiobo OW bit@ and @moot to filo boat of my knowtod.go, Polo MONO MOII to AFIZOI1O Doportmont of Rovonuo, PO Box 2C010, Phoonix, AZ 66038=0010 (t102) 716-1801 APO 10gP1(1114) Provim Y1.1003 (QM Bingo This affidavit must ha aomplatad lyaa@lt parson who wishas to assistin tha ndust of any gama of hingo, If any information is blank or ingorrad, tha affidavit will ba ratmonad to you. All information Is subjact to varifigatton, Lfisglosura of your Social 5acurity Numbar (N) ig voluntary, This information may ha usad to otahlish pOSitimigOrititlgOtiOrl for otirgPaag Of gillfiltIO1 OMcligtOtlild CtiOckO 1411FAVATIt to Arlon a ROVI§Off 5tott1tOO &AK Lippn§@@f§fipnip - WOW NO11101 "Dre.a.vvv.0-4.A.A C- ) 0 – 3 '3L, -13 Position (ohol thoappropriata boriogy Monagor n kiptirvim. _ptcrpo ClOtlftliflOtOr AO5151411t VNU ff WET °NV!: PO NOT MARK IN TRIO ARP& Affianra Noma Tervi-Nin FloSIA14444nrity-Ntmmtta Artitraria, Work hono No rwith WEI§ Q1100 If lioanrioa i§ gollflod organization, comploto tho following 000tIon; Mon-filar? Data doinad Organigation Mos n Ne 7 i / 1 2-04 7 , , 4m§ _Lr:1 No tp an,t1 h Oil vOlillOY itl affidivit on fib o for AO Omar lictiriai? — — — 1:1 Vow JNo If Vow liOt UPON@ nuntbsidn)i o‘. rd „ALLA... v1/4..L.A.ck , ow tomvp,Thollod amo, undo!' malty of pOory, npon oath, tignoti@ AFFore-g-rimg- and hay that I will oonduot or assist in Ponaug(ing all king() mune§ in compliance with 11w forms of fito How; Arizona Ro.vihod Ntatuto, DI@ 5, Chapwr Kt. and the 11110 OM@ licaming mititority. I OM Orood moral altimeter and have never been eonvicted of any nthiclonetmor involving moral itirpitude or felony, I 1111VO not and 1wi1 not receive any rewuril compamattion or recompuntie thr my participation in the conduct of bingo game§ exeept to provided for by law, I hereby WOW 01: oulimni that I how rend and miderfitand the thregoing and verify that the information and atatentenni made herein am 11mw and porToot to limo bp.t of my lotowl@dp: cc o (2_ _4iL_aC, 5- DWI Roam mail to; Arizona Popartment of Rovonuo, PO Box 20010, Phoonlx, AZ 86038-0010 (002) 710,7801 APPR 10:MY 11/14) PIPVif10§ 71 ,1P05 0106) Bingo Thia affidavit mug ba complatadhyoh FAMPli who Wigh@i§ to N§I§t in triO GOMM of any gaMO of bingo. If Priy information la blank or Ingorroci, tha affidavit will ho rotionod to yon, All Information la aubjagt to vorfficatlon Olacloatiro of yonr Social Ooc nay Numbar (IN) fa voluntary, Thia information may ho W4O.f1 to EgtAlIgh pO4Itili@ 10intiflOtiOn for pLifp@@§ of CrimInftl background chooka prawn to Angina PAVI.§..0 Motto§ 00.04, tLiaanag'iNamo CiNir o -i3ZB 6- 62 rt_Y"r•s 1 a 14 j V ( C rY\ vt-t.0 0.; (-Ai otub ,tJ 6/ S- / 6 39 7-Ax• -4) • PI:Align Monk the approgriato bcoroa) 100112.91_ ,F grthinOrif§OF i RITIVVIKI GOPtclintliOF Erinfaiatant VNNIJE WOK ONM 00 NOT MANN IN TM@ AREA, Homo. Phnno Mo i oftia ode" Work Pliono No (Win RNA 040 If lioeneee I o uollfied orgenlzetion, oompleto tho followino motion: Monthor? Onto Joinod Organiga(ion e Ygo III No 1 ,3_ r o r 1 ,_;2.01) fiNf§? 4 • II CO' We ig1 YO§ ;a No boa ca (V\ € at re Po yon haw on WOW on filo for any War karma? 'rl Yog j21- No If 'Non". lifit linfing15 nombnr(o): L CAeol S Coo 0-e_r [ho atiovo.nonipti tan% undo' molly of poduty, upon oath, (Wpm@ fv,rvint ri/SME anci gay find I will goiniugt or imigt itt gontingling ail bingo um§ eomplinng@ with tit@ ming of (ho 1iQonO Arizain Wvi§ott fitatuip§, Till@ Chaptor dig tido Mho lima* authority, I um .of gooa IWOf fluorin/tor und itavo inivor Non gonvigtga of any iniationtounor involving moral tornitufig or folonyA ituvg not and hholl not wg@iv@ oily 1owurtL goinpunhution rocompow for toy patligiption in filo goofing of bingo pow§ @limn wi provitiod Mr by law I horolly moor or @Olififill ibtlt I !IRV@ Ntid 11VO forgoing and vorify thin (ho information and ittingtoging inn& ligroin OW into find oorroot to (ho boot dilly kitowlotim: 4.4 .u. Dam Plagt moil to Arlionot Deportment of Revenue, PO Box 2e010, Phoonlx, AZ 85036.0010 t (002) 710-1801 AOON 11/14) Ptolgo§ 71 ,403 (AIN) Affidavit Bingo Thi§ affidavit mug be completed by each per§on who wi§he§ to a§clgt in the conduct of any game of bingo. If any information i§ blank of InCOrrod, thO affidavit will be returned to you All information l§ §ubject to vet -Nation, 15l§olo§tire of your Social Security Number (N) i§ voluntary, Thi§ information may bo u5@ti to Ntabligh pogitive identikation for purpo§e§ of criminal background checM purgiant to Arilona lievi§ed Statute§ e PIK Liaorma'§ Name \ Lioonae Number R o -2-33(.- lao§itien (Moak tho appropriate bon§ ; MAflOgOf Sitiporviaor Pronood Coordinator )14 A§§i§tant M Y@NLIg UN@ ONLY, DO NOT MARK IN THIN AREA: &Loma LEM SO ROVE, AMO Hono No lf€14 Work Phone No (with oF@Al If lioon000 lo§ WOUND Of mintion, comploto tho following sootlon; Momnor? Dia JOIO0€1 Org tillirtiliOn A YOO CI No 7 1 a..,$ 0\01 a-- MOM? OfflOOF Till@ CI WM A No Do you hayo an OCIOVit on fll@ for any other ligenee? 11 Yee A No If "YIN", fiat 'loom numbor(o): T, A -8. U, &-ct YY\OVIAO\ , the rthove.nmued atnant, under penaity of podury, upon oath, (Wpm A-MAICO-NAM" find §ny Mg I will oonduot Of ONlibit In oonduoting all bingo gamoa in oomplianoo with Illo MIN of tho Arizona ROVigal StittUtO§3 Titio 5, Chaptor 4, and tlw Mos (Mk lloonaing authority, I um of good mond oltarootor find havo NWr boon oonviotod of any mi§domermor invoiving moral turpitude or felony: If not and attail not r000ivo any rowttrd, oomponmation or r000mponao for my ptirtivipittion in filo oonduot of bingo ganwa exoopt a providod tbr by low, I horoby wont' or MINH that I haw road and inid@ranind Ma forgoing and way that tha information and 'Mignon% ma& horoin aro into nod uorroot to tho boat of my knowlodgo, •S 1 Nino@ moll to Arizona Doportmont of RDVDDLID, PO Box 20010, Phoonlx, AZ 88038=8019 it (002) 710=7801 APPF4 1N§07 (1114) fifoloom 71:1N05 (COM Thio affidavit frillgt ho mplat by @Nit gown who wioho§ to o§§i§t in tho conduct of ony gamo of bingo: If ony information i§ Monk or incorroct, tho affidavit will ho roturnod to you. All informotion I§ §ubjoct to vorincation, Cloclo§uro of your Social Socurity Numbor (SSN) io voluntary. Thio information may ho uood to ootobli§n no§itivo idontification for ourpoog of criminal background chock ourouant to ArIROFI@ FWV1@@fi 5tatutg NR§tio §Nmo Lioon§o Numbor J)rea-M lork.na V: i C Ni1§1P011 (Gh@di WI@ opptcpriato hem): Managor titioroyicor Fri:mood Coordinator 'SI A§§immnt I WNLIO NE ONLY 00 NOT MANN IN MO ANPA: Igtiatia Wimp Nn. iwith araa W i Phono No (with won woo) If lloofiw lo quolifiod orgonization, oomploto tho following 000tion; Molillb0 NM Joimla Org8fliMil@l1 Yoo Li No Cr( ,' 2- I / [ 2-o ) 2_ Mare p . ram; pr ygm r-Np ei Me On you hov on ffirlavit on filo for any °IMF lloon000? 13 Yoo o If "Yoo", Hot Homo norohor(§): e_4 -__ tho ahoyo-nomod afilam, 'maw' ponalty podury, upon oath, &pow FrIANITTIAM anil §ay that I will c onduct ui ag§i§t hi oonducthtg all bingo gliMV8 in oomplialloo with lho tonno of tho Homo, Arizona Itoviwil Iiitatmog, Till@ 5, Chaptor 4, anti ho ruloo ofilto Booming authority, Tarn ofgood moral oltartiotor mid Imo ll@VOf hvou oollyictod of any miglomottnor involving moral tttrpitudo or folony, I how not and Mali not MOM any vomit compomation or r000mpon§o for my participation in tit@ conduct of bingo g11111Pfi ffeflit uo providod for by law I boroby owoor or confirm thin I !IRV@ rood and undorhiond tho tbrogoing and yorify that tho Information and gramma motto horuin tiro Woo and corroct to (ho bog of my knowlodgo, / )2, ) 000 of Mimi-) Plum moil to AFIZOTIO Doportment of ROVOFILIO, PO Box 20010, Phoonix, AZ 85038-0010 ni (602) 7164801 A000 10327 (1/14) Prpvlon 71=1002 (4100) Affidavit Bingo Thio affidavit mat bo complotod by aach por§on who wlahogtoaaalct in tho conduct of any gama of bingo, If any information io blank or Incorract, tho affidavit will bo roturnorl to you: All information io oubjact to vorincation, Diaclogura of your Social Sacurity Numbor (SfiN) i voluntaiy, Thio information may to load to gtablioh go§itivo idontlfication for ournooco of criminal background chock§ ourougot to Arizona Rovizod Statutoa SAM: Ltoonago% Nom 0 - 3 obition (ohook (ho oppropnato bozoop faMort000r OODorvi§or PrOoD011 Coordinotar A§§igimit I MMO NO ONLY: DO NV MARK IN AMA: I.I PM On If lio§n§oo I§ o quoliflod organIzotIon, oomplot§ trio following no Ion; NitifilMr? Onto AillPd Or000iZgii0P1 pi Yo § IM No a. I I i t2-0 /,•‘'. Officoro9 Offloor Tin@ izi kttg pi No On you havo Nn onioVii On MO for any othor ligon§aa? 0 Voa_DINo If "Yon". Hot lloonoo ourribor(o); 1,C71a-- M (2t± Iho fillOVo.DOMPti OBRA, MidOr p@Milly Of potjuty, upon oath, dopoho mid oily (hot I will gonthig or mint lit oonduoting ail bingo gainOaIn goinpliono with iho min of tit@ HOW; MIODO 'Wind %OWN; TitiO Chupwi 4 and tho ruloa oftho ItOOnthig authority, Torn of good moral oharaotor and haw nowt' boon oonviotod of nay niladomonnor involving moral mrpitudo or Molly, I haw not and obit not ROOM any roward, oompomation or r000mponao for my portiolprOlon In tho cooduoi of bingo gam§ omoopt ma providod for by law I horoby sway or vonfirm that I him road and undoratand tho forogoing and voritY that tho information and atatomonta mad@ horoin rirO trim and ourroot to (ho hoot of my knowlodgo, ID1@firgi mgd1 to Arlon@ Doportmont of Rovonuo, PO Box 20019, Pho§nlx, AZ 86038=0010 el (002) 710=7801 AMR Man 11/14) Pre0o§li ,-1004 (4n) Thig affidovit intigt l omplatod by gach pargon who %Moho to aggiat in tho conduct of any gam of bingo, If any information ig blank or iriEDIT@Ct i, th affidavit will bg roturnod to you, All information ig gubjgct to vorification, Pigdoguro of your 5ociol Socurity Numbor (N) ig voluntary, Thig information may ha uggd to gotabligh pogitivg Idontiffcation for purgogag of criminal background chock§ purguant to Aril.ona Rovigg€1 atatutog Orgind, Iipong@o't Ngmg. 'ElTango Numbor urz e) %AA ce 01 k Rogition (ohook thg opprouriato lgokag)i Matwiff fel Num -vigor _PrOCagri Coordinator Aggigtan YgNUR UPD OW: DO NOT MANN IN THID ANA - fint'a NAM 3 1Ei = • OrK PhODO No (with offIg @ado) KJ rre_ If harmer it D quallflad organization, immolate tha following @action; Morobor9 Doto Joincid Organigation 0 Yon _1010 la=a6A-0-it Ott loom? Moor min n yt1§ pi No On you hovo on offidovit on filo for ony othor Ilogrigoo? rt yiln m No If "Yno", llot Homo@ numnorin); oLevs.es De,\KN ,tho Rbovp.mtitial nf11oiit undor ponnity ofpodu ry, upon *oho arriaramatt and gay that will miligt ni utibla hi eonclooting albino gi11110 in oomplimtoo with Jim tonno of ID@ 1ioono Mizono Rovisoil Ntotutoo, Tido 1, Chaptor 4, mid tho .roloo (Mho IloonHing nothority, I am of good MIA olutritotor and MVO nom boon oonviotod of ony iniodomoonor involving morn] I-omit-tido ni M011y, I linvo not mid Anil not roogivo ony mount, oomponoution or r000mponoo for my portiolpinion in tho coming of bingo grotto mow no providoti for by taw, I horoby hWoor or vonfirm thin I hovo rood nod ondorotand tho hvogoing mut vorifY thin tho information mid otatomonto tondo boron' aro trim mid oorroot to lho hoot of tny lotowlotige, laca Mono@ moil to: Arizono Doportrnont of Rovonuo, PO Box 20010, Phoonlx, AZ 85038=0010 /2 (002) 710=7801 ADOil 1OT (1114) Drovi@w5 71=1005 WOO DREAMLAND VILLA BINGO 6159 E. University, Mesa, AZ 85206 Monday: Games Start at 1 p.m. You must be 18 years of a ge to pla y Bingo. You are not allowed to split packs. You must Bingo on the last number called. Once the caller starts to call the next number or letter of the next ball, no previous Bin go will be honored and the game shall continue. You must use a dauber to mark your cards. Please be considerate of the other pla yers. Loud talking or disruptive behavior will not be tolerated. Please silence your cell phones. P4 GOOD LUCK AND HAVE FUN? GAME 1 SPECIAL GAME 8 Betty Boop ip Picnic Table (as shown) 70, 80, or 90% payout IIII Gray Boarder 11.11111. $100.00 UWE. GAME 2 GAME 9 X-mas Tree (as shown) Elm Lazy E (as shown) Blue Border ini Olive Border =I $100.00 $100.00 GAME 3 GAME 10 4 Corners Any Regular Bingo Orange Border Brown Boarder $100.00 $100.00 GAME 4 GAME 11 ' Anchor (as Shown) Wild #4 Corner Triangle (4 combinations) Green Border Red Boarder $100.00 $100.00 GAME 12 Champagne Glass (as shown) Wild #5 Yellow Border Purple Border NM $100.00 $100.00 11111 GAME 6 SPECIAL GAME 13 Small Diamond & 4 Corners Pot of Gold — Coverall N•' Pink Border Yellow Solid MIN $100.00 80/20 EMI 1/2 18/ 33/ 51/ 61/ SPECIAL GAME 7 19 34 52 62 Double Action 4/5 20/21 35/36 53/54 63/64 Coverall Color Orange 6/7 22/23 free 55/56 65/66 70/30 8/9 24/25 39/40 57/58 67/68 10/11 26/27 41/42 60/49 69/70 INTERMISSION DREAMLAND VILLA BINGO 6159 E. University, Mesa, AZ 85206 Monday: Games Start at 1 p.m. You must be 18 years of age to play Bingo. You are not allowed to split packs. You must Bingo on the last number called. Once the caller starts to call the next number or letter of the next ball, no previous Bingo will be honored and the game shall continue. You must use a dauber to mark your cards. Please be considerate of the other players. Loud talking or disruptive behavior will not be tolerated. Please silence your cell phones. P3 GOOD LUCK AND HAVE FUNI GAME 1 SPECIAL GAME 8 • Betty Boop IIIIIIII. ODD/EVEN Coverall • 70, 80, or 90% payout = 50/50 111/ EMU GAME 2 GAME 9 Hangman's Knot Double Bingo Blue Border Diagonal and Straight Line $100.00 Gray Boarder • $100.00 GAME 3 GAME 10 Lucky Seven (as shown) Top OR Bottom T Orange Border Olive Border $100.00 $100.00 GAME 4 GAME 11 Corner Stamp & a Line (No diagonal) Crazy Small Kite (alt ways) Green Border Brown Boarder Ell $100.00 $100.00 IIIIII GAME 5 GAME 12 9-Pack anywhere Double Stamp from any corneer IIIIII Yellow Border Red Border MIMI $100.00 $100.00 1111111 GAME 6 GAME 13 Missing Link Right or left flag (on top only) Pink Border Purple Border II $100.00 $100.00 111111 1/2 18/ 33/ 51/ 61/ SPECIAL GAME 7 SPECIAL GAME 14 19 34 52 62 Double Action Pot of Gold—Coverall 4/5 20/21 35/36 53/54 63/64 Coverall Yellow Solid Color Orange 80/20 6/7 22/23 free 55/56 65/66 70/30 8/9 24/25 39/40 57/58 67/68 10/11 26/27 41/42 60/49 69/70 INTERMISSION DREAMLAND VILLA BINGO 6159 E. University, Mesa, AZ 85206 Monday: Games Start at 1 p.m. You must be 18 years of age to play Bingo. You are not allowed to split packs. You must Bingo on the last number called. Once the caller starts to call the next number or letter of the next ball, no previous Bingo will be honored and the game shall continue. You must use a dauber to mark your cards. Please be Considerate of the other players. Loud talking or disruptive behavior will not be tolerated. Please silence your cell phones. P2 GOOD LUCK AND HAVE FUN1 GAME 1 SPECIAL GAME 8 Betty Boop Outside line & 1 opposite Corner 70, 80, or 90% payout Gray Boarder GAME 2 GAME 9 Goal Post (as shown) Check Mark (as is) Blue Border Olive Border ml $100.00 $100.00 1111 GAME 3 GAME 10 Heart Double Plus Sign (as shown) 1111111 Orange Border Brown Boarder En $100.00 $100.00 NMI GAME 4 GAME 11 Large Diamond Chevron (4 combinations) Green Border Red Boarder $100.00 $100.00 GAMES GAME 12 ii iiii Plus Sign Emm Regular Bingo OR 4 Corners Yellow Border Purple Border 111111 $100.00 IIIII $100.00 Milli OMEN GAME 6 SPECIAL GAME 13 7-11 Wild #7 Pot of Gold —Coverall Pink Border ill Yellow Solid $100.00 11111 80/20 INN 1/2 18/ 33/ 51/ 61/ SPECIAL GAME 7 19 34 52 62 Double Action 4/5 20/21 35/36 53/54 63/64 Coverall Color Orange 6/7 22/23 free 55/56 65/66 70/30 8/9 24/25 39/40 57/58 67/68 10/11 26/27 41/42 60/49 69/70 INTERMISSION DREAMLAND VILLA BINGO 6159 E. University, Mesa, AZ 85206 Monday: Games Start at 1 p.m. You must be 18 years of age to play Bingo. You are not allowed to split packs. You must Bingo on the last number called. Once the caller starts to call the next number or letter of the next ball, no previous Bingo will be honored and the game shall continue. You must use a dauber to mark your cards. Please be considerate of the other players. Loud talking or disruptive behavior will not be tolerated. Please silence your cell phones. P1 GOOD LUCK AND HAVE FUN! GAME 1 SPECIAL GAME 8 Betty Boop • m ODD/EVEN Coverall • 70, 80, or 90% payout 11 .. .. 50/50 II IN III 1111 GAME 2 GAME 9 Division Sign (as shown) An Y Two 3-Corner Brackets In Blue Border Gray Boarder 111 $100.00 $100.00 MIN GAME 3 GAME 10 rn iiim Large Diamond (as shown) Top OR Bottom Line MI Orange Border Olive Border 110111111 $101100 III $100.00 • 11111111 MIN GAME 4 GAME 11 3 X3 X3 Crazy Arrow (all ways) Green Border Brown Boarder $100.00 $100.00 GAME 5 GAME 12 Double Hard way (no free space) • 6 Around-the-Corner Yellow Border II Red Border $100.00 II MEI $100.00 11 EMI GAME 6 GAME 13 Stamp & Diagonal Letter X Pink Border Purple Border $100.00 $100.00 1/2 18/ 33/ 51/ 61/ SPECIAL GAME 7 SPECIAL GAME 14 19 34 52 62 Double Action Pot of Gold — Coverall 4/5 20/21 35/36 53/54 63/64 Coverall Yellow Solid 0/7 22/23 free 55/56 65/66 Color Orange 11 80/20 70/30 8/9 24/25 39/40 57/58 67/68 11 10/11 26/27 41/42 60/49 69/70 INTERMISSION