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Arizona Department of Revenue Application for Bingo License Packet
This Application for Bingo License Packet includes:
e Arizona Form 833 — Application for Bingo License
e Arizona Form 830 — Affidavit
® Arizona Form 832 —
Endorsement by Local Governing Body
It is advisable that you obtain and review a copy of the
Arizona Revised Statutes on "Games of Bingo” and the
Administrative Rules prior to initiating an application,
These documents outline qualifications and requirements
for obtaining a bingo license and may be obtained from:
* www.azleg.gov/ and
* www.azsos.gov/public_services/table_of_contents.htm
All forms must be complete and legible. Please type or
print using black ink only, Forms are available in a fillable
pdf format at Arizona Department of Revenue (ADOR)
web site www.azdorgov. Be sure to include on your
application a telephone number where you (or another
party responsible for the games) can be reached during
the day.
cnn city council for incorporated cities or the cou!
board of supervisors for unincorporated areas)
Upon their
Endorsement by Local Governing Body and submit to
your local governing body with the bingo license package.
A bingo license cannot be issued until this form is
received by the ADOR Bingo Section.
As part of the review of your application for a bingo license,
the ADOR Bingo Section will conduct an analysis of any
purchase agreement for either equipment and/or real
property to determine that such agreement is bona fide.
This analysis is conducted pursuant to A.R.S. 5-406.F. The
Bingo Section does not “approve” these agreements as to
contentor other legal ramifications. You are strongly advised
to consult with independent legal counsel to determine your
rights and obligations under these agreements.
If you need additional forms or have any questions, please
call the “RB E¢ Section in Phoenix at (602) 716-7801.
CEIVED
JAN 22-2025
MARICOPA COUNTY
CLERK BOARD OF SUPERVISORS
CHECKLIST:
Send copies of all documents listed below unless otherwise
noted. Before mailing, check to make sure that you have
included the following:
1] Original completed Application for Bingo License
(Arizona Form 833).
2] Original completed affidavits (Arizona Form 830).
Class B and Class C applicants must include a
completed affidavit for each person participating
in the conduct of your games. Class A applicants
must include a complete affidavit for each person
participating as a manager, proceeds coordinator
and supervisors.
3 Rental agreement if more than one licensee is using
the same rented premises in which to hold bingo.
4] Application for Special Bonus Game (Arizona Form
831) available at www.azdor.gov. If you do not
conduct special bonus games do not complete the
application.
5L] License fee payable to the Arizona Department of
Revenue:
License Type Fee
|ClassA | __—*$10.00_|
Class B $50.00
| Class C $200.00
6L] The local governing body fee will be payable to the
appropriate local governing entity:
License Type Fee
ClassA $5.00
Class B $25.00
Class C $50.00
7 If applying as a qualified organization, a current
membership list must be submitted and must
indicate initial membership dates for all members
of the applicant organization. Any person from any
branch of the applicant who will be participating in the
operation of bingo games must be included on the
membership list.
s(] If applying as a qualified organization, the following
must be submitted: charter documents, articles
of incorporation, corporate bylaws, articles of
association, minutes of the establishment meeting,
and minutes of meetings for two years (two months of
each year) immediately prior to the date of application
for the applicant, parent and auxiliary.
9C] Purchase agreement for real property (where
applicable).
10] Purchase agreement/bill of sale for bingo equipment
and supplies.
111 Original local governing body endorsement.
ADOR 10331 (1/14)
Arizona Form 832 Endorsement by Local Governing Body
FOR OFFICIAL USE ONLY PURSUANT TO A.R.S. § 5-404.A
e
Bingo
e License Applicants: Complete lines 2, 3, and 4. Submit with entire license package to local governing body.
e Local Governing Body: Complete and return with license package to the Department of Revenue Bingo Section.
A.R.S. §§ 5-409 and 5-410
(J New Application
(J Change of Location
Date
License Number
From (Name of local governing body)
a
Address (number and street, PO Box)
[3]
City
State
ZIP Code
Phone No. (with area code)
EVENUE USE ONLY. DO NOT MARK IN THIS AREA,
fea] PM
RCVD
1 This is to certify that on a hearing was conducted pursuant to Arizona Revised Statute, Title 5,
Chapter 4, in the matter of:
(1 Application for a bingo license by the following applicant.
C1 Application for a bingo license location transfer.
2 Applicant's Name
Superstition Buttes Activity Club, LLC
3 Location/Address where live bingo will be conducted: | City State |ZIP Code
301 South Signal Butte Road, Clubhouse Apache Junction AZ 85120
4 Fill in the time on the days live bingo will be played:
SUN MON TUE WED THUR FRI SAT
Dam. Ham. Oa.m. Olam. Mam. Oa.m. a.m.
; Op.m.}8:30___ p.m.) Op.m. | s p.m.) :Op.m.|e :Op.m. Op.m.
5 Whois your live bingo supplier?
6 Recommendation for the application: [] Approved
C1 Disapproved
7 Specific reasons for disapproval are hereby listed pursuant to A.R.S. § 5-404.1:
PRINTED NAME
This endorsement must be signed by a delegated authority of the local governing body.
SIGNATURE
DATE
TITLE
Please mail to:
Arizona Department of Revenue
1600 W Monroe Street, Division Code 22
Phoenix, AZ 85007
® (602) 716-7801
ADOR 10326 (2/20)
Arizona Form 832 Endorsement by Local Governing Body Bingo
FOR OFFICIAL USE ONLY PURSUANT TO A.R.S. § 5-404.A
e License Applicants: Complete lines 2, 3, and 4. Submit with entire license package to local governing body.
e Local Governing Body: Complete and return with license package to the Department of Revenue Bingo Section.
A.R.S. §§ 5-409 and 5-410 na ‘ies Uaioe?
ccd se a Change of Location Di OF 26 AS SV 1-36 1 = Ry
= i ye pe stot in " B codes Aen \ Vit Y Clu | VENUE USE ONLY. DO NOT MARK IN THIS AREA,
see ha and sire! (ay nal Ry Ro Ex 88
City Ae Ane ef e Than Cron State AL oe o /20
Phone No. (with area coda)
PM RCVD
1 This is to certify that on UM) 1) YY ya hearing was conducted pursuant to Arizona Revised Statute, Title 5,
Chapter 4, in the matter of:
Application for a bingo license by the following applicant.
C1 Application for a bingo license location transfer.
2 Applicant's Name 4
supsestition Qutes Aerivity Club
3 Location/Address where live bingo will be ens
Sar SoVScqnak Gutie.
Cit State [ZIP Cod
“A racite § unertor AZ ¥S/2O
4 Fillin the time on the days live bingo will be played:
SUN MON TUE WED THUR FRI SAT
Olam. 6:3 Olam. Olam. Ola.m. Olam. Olam, Olam.
— p.m. |. 10 EJp.m.}. :Cp.m. |. Cp.m.|. —__sCp.m.|i Cip.m. Op.m.
5 Who is your live bingo supplier? Cactus Bingo = Phoen : hy 2
6 Recommendation for the application: [1 Approved [1] 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
$2 (602) 716. 7801 Seer es 6 any
TIE —atat Tee,
al ci NOLLONNLSHDVdY 40 ALID
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 live bingo games, you must renew your license
prior to the expiration date pursuant to A,R.S, §§ 5-403(C) and 5-41
0.
1 Applicant's Name
SUPECCTITIO
» Buttes Aare rl lob
Falsification of information
2a Mailing Addr
‘a Ing Fé Sicreat Que Be eet
contained in this application
constitutes a Class 6 felony.
(
3oO\
State
2b City =
APACHE duUNneTION
ZIP Code
RGU FS/aAg
REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
3a Administrative Office Logation
30 sX&Scrgn
at Ontte #43!
tate
et
3b Cit
factte Aunexren
ZIP Code
IS12A0
ne of Contact Person
N
PM RCVD
A
§ Class B and Class C license applicants only: If applying as a qualified organization, check one box to indicate the type of
organization:
(1 Charitable
(1 Fraternal
o
a
1 Social
(1 Volunteer Fire Department
(1 Veterans
(I Nonprofit Ambulance Service
Religious
Homeowners Association
Class B and Class C license applicants only applying as a qualified organization, provide parent or auxiliary information:
6a Parent Name
SuPeestitiea Ruurres Lyn
6b Auxiliary Name
yity Club IBAC
Address — Number and Street, Rural Rt., Apt.
3e( Sie nob Butte 24 62
‘Address — Number and Street, Rural Rt, Apt. No.
‘DOL S wvyth§iqgaat icxte ON b 2!
Sox
City Tt State ZIP Code
APac te \uncmian KZ 8S /A0
Cit J State ZIP Cod
" APheHE J uneTion Az P5120
Class B and Class C licens
Directors of the organization:
applicants only applying as a qualified organization, list the current officers or Board of
7a Name
ogew Rorts
7
Title Adver 4i Saney
Tile
Ente rte ment
A
7c Name
Teenng Beuce
7d Name
Lolo. Sshadowen 4
Tith
C haivrPersen
Till ie Craw eer so
State ZIP Code
Clty
|
Class B and Class C license applicants only: Bingo checking
7 iW
account information:
a Account Number
C Name
Sec a ache tsT
rss
Continued on page 2 >
ADOR 10334 (2/20)
Applicant's Name (as shown on page 1)
Suffers ririon io) ules Aer wr? Cle __-APPLICATION FOR BINGO LICENSE
9
10
"1
12
13
14
15
16
Class B and Class C license applicants only: Bingo interest-bearing account information:
Account Number Bank Name Bank Branch
NYA
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:
10a race \ x S { =. 10b Name
Title .—" Title
Financial Manogec
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.
Via Ne eS (nau (oc psa 21 an Bard
Title Title
Manaqec Manage c
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 taro | er Stuact igi Irae ( Mar
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. If additional names are required, please attach affidavits.
13a Na Name 13b Name ;
Vames Gowler Beira Aaird
Title Title
Sure rwsor Supetvi sot
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.
44a Ni 14b N
“Wlorgacet Coy lor im aw FE lekcher
14c Name 14d Name
Richacd Noth nesel Martine Clourier
Street address 0 of the PHYSICAL location where live bingo will be pre
ao| 5S. Sie nat Pret (| Neer A ap AZ 6S/aO |
Games of Bingo must not exceed 5 days a week. Indicate the time on each respective day that live bingo will be played:
SUN MON TUE WED. THUR FRI SAT.
Olam. b: Olam. Oa.m. Dam. Oa.m. Ola.m. Olam.
Cpm.|.2' 20 _Pp.m, Cip.m. .m. [p.m. O)p.m. |. [p.m
Continued on page 3 >
OOrTHd GZ. 6 NUL
NOLLONNSHOvdY 40 ALIS
ADOR 10334 (2/20) Arizona Form 833 Page 2 of 5
Applicant's Name (as shown on page 1) —= ora hes
SuPer Shrion Burtes HPoenvilm ) APP
17 Indicate the type of premises where bingo will be played. Check one box:
ATION FOR BINGO LICENSE
a sg 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 (©) 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 (J Owned jointly with other organization, Attach copy of mortgage, deed of trust, purchase agreement, escrow agreement, or
other related document:
41) 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 2\P Code
3) Co-Owner Holder: Address — Number and Street, Rural Rt., Apt. No.
Telephone Number (with area code) City State ZIP Code
18 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:
18a Name No NE 18b 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
Continued on page 4 >
00: TH4 SZ. 6 NBS
NOTLONALSHdY 30 ALI
o
ADOR 10334 (2/20) Arizona Form 833 Page 3 of 5
Applicant's Name (as shown on page 1)
APPLICATION FOR BINGO LICENSE
19 Expected bingo expenses:
a
d
20
Mortgage: $, per month
Payable to Address — Number and Street, Rural Rt., Apt. No.
Telephone number (with area code) City State ZIP Code
Rent: $. per(J month [J hour (J occasion
Payable to Address — Number and Street, Rural Rt., Apt. No.
Telephone number (with area code) City State ZIP Code
Janitorial Services: $._——=—S——S-Ssper{ month (3 hour (J occasion
Payable to Address — Number and Street, Rural Rt., Apt. No.
Telephone number (with area code) City State ZIP Code
Accounting Services: §, per month (J hour (J occasion
Payable to Address — Number and Street, Rural Rt., Apt. No.
Telephone number (with area code) City State ZIP Code
Security Services: §, per J month (hour (J occasion
Payable to Address — Number and Street, Rural Rt., Apt. No.
Telephone number (with area code) City State ZIP Code
Bingo Supplies: $_950.00 , per year
Payable to Address — Number and Street, Rural Rt., Apt. No.
Cactus Bingo Supples, Inc 3210 East Roeser Rd
Telephone number (with area code) City State ZIP Code
Phoenix AZ 85040
(602) 268-2848
Who is your live bingo supplier? (For all bingo supplies). Do you foresee purchasing/renting machines as “technological aids for
your live bingo games?
Cactus Bingo Supplies, Inc. 3210 East Roeser Road, Phoenix, AZ 85040 No purchaseor renting technological aids |
Continued on page 5 >
ADOR 10334 (2/20)
Arizona Form 833
Page 4 of 5
Applicant's Name (as shown on page 1) (ary ae ;
SUPERSTITION Bu TES Aer vityClelp APPLICATION FOR BINGO LICENSE
19 Expected bingo expenses:
a Mortgage: No ng, per month
Payable to Address — Number and Street, Rural Rt., Apt. No.
Telephone number (with area code) City State ZIP Code
b Rent: No Nee $ ___—,_ per month hour (occasion
Payable to Address — Number and Street, Rural Rt., Apt. No.
Telephone number (with area code) City State ZIP Code
c Janitorial Services: s None, per month CO hour (occasion
Payable to Address — Number and Street, Rural Rt., Apt. No.
Telephone number (with area code) City State ZIP Code
d Accounting Services: sNon&, per (J month OC hour (© occasion
Payable to Address — Number and Street, Rural Rt., Apt. No,
Telephone number (with area code) City State ZIP Code
e Security Services: s None. , per month C hour © occasion
Payable to Address — Number and Street, Rural Rt., Apt. No.
Telephone number (with area code) City State ZIP Code
heeded
f Bingo Supplies: $, , per
Payable to Address — Number and Street, Rural Rt., Apt. No.
Telephone number (with area code) City State ZIP Code
20 Who is your live bingo supplier? (For all bingo supplies). Do you foresee purchasing/renting machines as "technological aids for
your live bingo games? Cacrus Bingo Supply - wwe_do not Cores e
Renting o- NAG Fech
Continued on page 5 >
OO:THs SZ. 6 NUE
NOLLONALSHOdY JO ALIO
ADOR 10334 (2/20) Arizona Form 833 Page 4 of 5
Invoice #; CH05325
Cactus Bingo Supply, LLC. Date: 10/31/2024
3210 E Roeser Rd Suite 15
i Terms:
Phoenix, AZ 85040 Customer #:
800-544-0984 Whse/SP: 000/Lloyd Eas
PO #:
www.cactusbingosupply.com
SUPERSTITION BUTTES SUPERSTITION BUTTES
Sold To: 301 SIGNAL BUTTE, LOT 621 Ship To: 321 SIGNAL BUTTE, LOT 621
‘ APACHE JUNCTION, AZ 85220 Piva: APACHE JUNCTION, AZ 85220
MARY DIETZ MARY DIETZ
Item # Description Unit = Shpd BO _ Price Amount
9S14UP90UMB SONS 14UP 90-99036 BDR 1004 PK SET 1.00 - 579.59 $579.59
6761730
81450102 CASINO T.O. 1S1 36-45 GN AUD# CASE 1.00 - 271.11 $271.11
216616
2222 FREIGHT/DELIVERY - SCANNER EACH 1,00 - 15,00 $15.00
OO: THd GZ. G NUE
NOLLONNPSHOVdY 30 ALD
Tensuinnnmaty Net: $865.70
AZ $850.70 5.000% $42.54 Discount 0.00% $0 00
PHX $850.70 2,300% $19.57 : 3
MARI $850.70 1.300% $11.06 Freight: $0.00
Tax: $73.17
Cust Sig.: Fw hl Ht etn GO Pele 24 Total: $938.87
602-268-2848 Ordor Dato 10/11/2024
800-544-0984 Contact Margret
FAX - 602-268-3243 Contact JiM//Jean
Contact Phone
3210 E. Roeser Rd, Ste 15, Phoenix, AZ 86040 2023 Nood by 0
Customer #: SB Ship To:
Sold To: Suporstition Buttes Superstition Buttes
301 Signal Butte 301 Signal Butte
Apache Junction, AZ 85220 Apache Junction, AZ 85220
Extended Box
Code Description / Rotation Qty Ordered Price Price Count
18H14UPUMB _80 OR 90, ROTATE SERIES WINTER BINGO $579.59 $0.00
80,000 SERIES - CUT 4 BOXES=6V, 1 BOX=9S WINTER BINGO $579.59 $0.00
90,000 SERIES - CUT 3 BOXES=9S, 2 BOX=6V WINTER BINGO |Z 1.00 $579.59 $579.59
$0.00
$0.00
6V15UPUMB1-9 SUMMER BINGO $623.15 $0.00
F3V2736PU $42.65 $0.00
F3V2736TN $42.65 $0,00
F3V2736YE $42.65 $0.00
F3V2736BK $42.65 $0.00
$0,00
STEAROPEN45GR 1.00 $271.14 $271.11
STEAROPEN54GR ¥ $271.14 $0,00
$0.00
IDF4 40Z DABBIN FEVER, PER DZ $13.64 $0.00
MIXED $0,00
41303 BULBS $1.68 $0.00
$0.00
$0.00
$0.00
$0.00
$0,00
$0.00
| $0.00
EQUIPMENT IN HALL: STATEMAN CONSOLE AND BK FLASHBOARD Subtotal $850.70
Tax $73.16
NOTES: PLAY ON MONDAYS @ 18:30////KUNZE6633@MSN.COM TOTAL
SUMMER BINGO-DELIVER TO FRONT OFFICESUMMER BINGO CHANGED TO 15UP UNIMAX 03/22/2022 Delivery $1.00 sii
Date Delivered: |signature: TOTAL $938.86 0
DELIVERY RECEIPT ONLY 00: THd SZ, 6 NUL
NOTLONNLAHOVAY 30 ALTO
TO: TH SZ. 6 NUL
NOLLONALSHOVEY 30 ALTO
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2 Weed
stars 1
44066
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NOLLONNCSHOUAY 40 ALTD
ARIZONA DEPARTMENT OF REVENUE
BINGO LICENSE RENEWAL APPLICATION
REVIEW ALL INFORMATION TO INSURE IT IS CORRECT. If changes are needed, indicate such by crossing out inaccurate
information and writing in the correction, PRINT IN RED INK. All information is subject to verification.
LICENSE FEE: CLASS A - $10.00 CLASS B - $50.00 CLASS C - $200.00
PENALTY FEE IS 100% OF RENEWAL FEE IF LICENSE IS NOT RENEWED BY EXPIRATION DATE
FAILURE TO RENEW WITHIN THE THIRTY DAY GRACE PERIOD RENDERS LICENSE NULL AND VOID
Attention: Bingo Manager
Superstition Buttes Activity
301 S, Signal Butte #709
Apache Junction, AZ 85120
LICENSE NUMBER: 07-367-B LICENSE EXPIRES(5/31/2024
Date Mailed: 4/15/2024
ADMIN ADDRESS: 301 S. Signal Butte #79.@ al
ADMIN PHONE: ¢83122%-9000- 77 /- 540-70 af
PLACE WHERE GAMES WILL BE HELD: 301 S. Signal Butte Clubhouse
DAYS AND TIME OF OCCASIONS: MON@6:30PM November [~ (Na roh 3p
DATES OF PROPOSED OCCASION CANCELLATION: N. one.
LICENSED FOR SPECIAL BONUS GAMES: —_No
(If licensed, attach documentation describing how you are conducting the special bonus game program.)
CURRENT OFFICERS:
Managers i Tames Goulet
; Bei A? Baicd
Fin andciel +s Karol Strar
STATE AZ
COUNTY OF D1 Ante ofa a/
Hh ro | 4) 2 ~S ‘ under penalty of perjury, upon oath, depose and say that I am duly authorized to sign and file
this splice Thereby swear or confirm that I have read this application and attachments and verify that all information provided is true and
complete to the best of my knowledge.
Please return completed application to: / Signature of Aig
Arizona Department of Revenue
Bingo Section - Division Code 19 TO:TH4 Gz B NUL
Phoenix, AZ 85038 NOLLONALSHOVAY 30 ALIS
LICENSE NUMBER: 07-367-B
PERSONS RESPONSIBLE FOR HOLDING, OPERATING AND CONDUCTING GAMES:
Listed are all persons who have a current affidavit on file with the Bingo Section which authorizes them to act in the capacity as
indicated, It is the responsibility of each affiant to insure the information reflected on their affidavit on file is current. Except for
Assistants on Class A licenses, ANY PERSON(S) NOT LISTED BELOW MUST SUBMIT AN AFFIDAVIT and receive approval
from the Bingo Section prior to participating in the conduct of your games. If any person(s) listed below will not be working your
games, indicated by crossing out their name. Indicate any other changes by crossing out the inaccurate information and writing in the
correct information, PRINT IN RED INK. Return all pages.
Note:For CLASS "A" License Only. The Annual Financial Report for CLASS "A" Bingo License, Arizona Form 836 must be filed with
the Arizona Department of Revenue no later than the 20th day of the month following the expiration of your bingo license. All Bingo
forms and publications are available on the website: www.azdor.gov.
MANAGER: PHONE:
ees |
SUPERVISORS:
Gayler, James
Stuart-Karot-
ReAN Bal rel
ASSISTANTS:
Berg, Keith Duchene, Nanette
Cloutier, Martine England, Joyce
Croucher, Donna Van Der Brink, Mary G.
DeBettean Duchene, Steven
Fletcher, Linda Baird, Brian
Gayler, Margaret Baird, Lori
Haeg-Pemiy- Smith, Candy
Houghtor kerr Smith, Jeffrey
Herron-Weber, Laurie Gilbert, Wendy
-Houghton-Ken
tenta-Jean-M.
Mata, Karen
Netson;Shesilya—
Nothnagel, Richard
Ouellette, Sylvianne
Shelbourne, Laurie
Thomas, Leta
Wallace, Diane
Warren Davide
Wilkens, Daryl
Windsor, Chris
“Basitra; Bit
Patterson, Dave
Ruhge, Jody
Stuart, Karol J.
PROCEEDS COORDINATOR: PHONE:
Stuart, Karol J
NOLIONNSHOUdY 30 ALIS
Bingo Li Questionnai
Licensee:
Please complete this questionnaire in its entirety and return it along with any supporting documentation.
Incomplete questionnaires will not be processed and will be returned.
1. What is your Bingo License Number?
O(-367-6
2. Please list all the license numbers associated with your organization. (if applicable)
A// A-
aici, 3
4. What is the address where the bingo games are being played
30! Sa, Svenat i Lol ~ Clibhovee
5. What is the mailing address of the licensee?
30! So. Signet fystte KA BEZI_ fyacheJuncron
F557 26H
6. Whatare your live bingo game hours of operation?
Mon eve. 6'380-%30 KUpYember Yhrut March
7. \saperson on the premises physically drawing and calling the numbers when live bingo games are being
conducted?
Nes C1 No
8. Does a secondary supervisor verify the live bingo game numbers?
Daves O No
9. Who is your live bingo supplier? (For all bingo supplies and equipment)
Lattus Lingo Sepplag~
= ]
10. Please provide a copy of your most recent itemized bingo order.
11. Do you Syne own or are you renting machines as “technological aids” for the live bingo games?
O Yes No
a. If yes, please provide a copy of your purchase or rental agreement.
b. If no, do you foresee purchasing/renting machines as “technological aids” for the live bingo
games? MM oO
TO:T Hd SZ, 6 NUE
NOLLONALSHSYdY 40 ALID
1600 West Monroe Street, Phoenix AZ 85007-2650 www.azdor.gov
12. If you have “technological aids,” are they being used in conjunction with numbers being called and players
physically present marking their own cards?
OYes CNo SfN/A
13. Print name of the preparer of this questionnaire.
Aarel Jean DStuar?
14. Signature Coordinator or Manager of this License.
the! address listed
Please contact the Specialty Tax Programs team at Bingo@azdor.eov or (602) 716-7801 with any questions or
concerns.
Thank You
Arizona Department of Revenue
Bingo Sect - Division: 9
TO:THd GZ. G NUP
NOLLONALAHO¥dY 30 ALID
Applicant’s Wa) (as ast oy tae uh "Laan eA re aa ali
UPERS TIT ION Buieés Hor Club lagi TION FOR BINGO LICENSE
I, Kato ely Stuac te , under penalty of perjury and upon oath, declare that I am duly authorized to sign
and fife 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.
y rhe wt jne-at "Jenaisiod Mays.
APPLI "S SIGNAT! DATE TITLE
rime o Disepproved (IClassALicense [JClassB License [Class C License
Reviewer's Name (please print) Date License Number Effective Date Expiration Date
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00:Thd SZ, 6 NUL
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ADOR 10334 (2/20) Arizona Form 833 Page 5 of 5
Pirnend ment-
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at: Posrh’ aaa -
Arizona Form
830
This affidavit must: be: completed by each persori wh: iishes to assist: inthe: Conduct of any gai
affidavit will Be retumed to you. All information Is ject: to: ‘verificatiol
may: be used to establish postive igentiic ication. for. pul
Licensee’s Name
SUPERSTITION BUTTES. ACTIVITY. Lue
Position (check the appropriaté-boxes):
Oo Manager mi Supervisor BA Proce Coordinator “s
rt bingo. -If-an informatio
Disclosure of your: Soci Securi Number |
ONLY..DO NOT MARK IN THIS AREA;
Affiant's Name
IKAROL JEAN-STUART.
Social Security Number
Date of Birth
ress
[ai] PM
Member?
Kl yes [No : :
Officers?. ; : Of cer Tile
Eyes. BRNo
Do you have an‘affidavit on file for any other oensea
DlYes -_BNo.” tf Yes";
I, KAROL JEAN STUART.
“AFFIANT'S NAME
salty of perjury, upon oath, depose E
and say that I will conduct or: assist i conus f
as of the: licen, ‘Arizona Revised:
and understand the foregoing and. ve exit th
knowledge.
ADOR 10327 (2/20)
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 js 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 A.R.S, § 5-404,
Licensee's Name
License Number
SUPERSTITION BUTTES ACTIVITY CLUB 07-367-B
Position (check the appropriate boxes):
Manager [2] Supervisor _[] Procead Coordinator Dassistant ge USE ONLY. DO NOT MARK IN THIS AREA.
188
Affiant’s Name
KAROL JEAN STUART
Social Security Number
y State ZIP Code
PM [gq] RCVD
lome 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
KlYes [CINo
Officers? Officer Title
Yes _ J No
Do you have an affidavit on file for any other licensee?
\ OYes BINo If “Yes", list license number(s):
I, KAROL JEAN STUART , the above-named affiant, under penalty of perjury, 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,
Sig fature Affiant
Date
Please mail to:
Arizona Department of Revenue
1600 W Monroe Street, Division Code 22
Phoenix, AZ 85007 aa]
® (602) 716-7801
ADOR 10327 (2/20)