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33
zona
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 5-410.
1 Applicant's Name
Super Sun Bingo
Falsification of
2a Mailing Address
702 S. Meridian Rd. Office
contained in this application
constitutes a Class 6 felony.
information
2b City State ZIP Code
Apache Junction AZ 85120
3a Administrative Office Location
702 S. Meridian Rd. Office
3b City State ZIP Code
Apache Junction AZ 85120
4a Name of Contact Person
Kimberly Storts
4b Telephone No.
REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
4c E-mail Address
4c Fax No.
[a] 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:
0 Charitable B Social 0 Religious O Veterans
O Fraternal O Volunteer Fire Department [J Homeowners Association 1 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, list the current officers or Board of
Directors of the organization:
7a Name 7b 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
7c Name 7d 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
8 Class B and Class C license applicants only: Bingo checking account information:
Checking Account Number Bank Name Bank Branch
Continued on page 2 >
ADOR 10334 (2/20)
Applicant's Name (as shown on page 1)
Super Sun Bingo
APPLICATION FOR BINGO LICENSE
9 Class B and Class C license applicants only: Bingo interest-bearing account information:
10
11
12
13
14
15
16
Account Number Bank Name
Bank Branch
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 Name
10b Name
Title
Title
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.
11a Name 11b Name
Kimberly Storts
Title Title
Manager
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
Mark Whitehurst
Title
Proceeds Coordinator
List the name(s) of the person(s) who will serve as supervisor.
member of the applicant. Each person must submit an affidavit.
If applying as a qualified organization, each person must be a
If additional names are required, please attach affidavits.
13a Name
Paul Streiff
13b Name
Title
Supervisor
Title
List the name(s) of the person(s) who will serve as assistants.
member or new member of the applicant. Except for “Class A” licensees, each person must submit an affidavit.
If applying as a qualified organization, each person must be a
14a Name 14b Name
N/A
14c Name 14d Name
Street address of the PHYSICAL location where live bingo will be played:
Sonchion ,
702 S. Meridian Rd. Agnarive
AZ. SS120 |
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
Oa.m. Oa.m. Oa.m. Olam. Oa.m. Oa.m. Olam.
\ iC)p.m. p.m. |. Cp.m. |. p.m.|_7:00___Bip.m. —[Cp.m,}_1:00___EJp.m.
Continued on page 3 >
ADOR 10334 (2/20)
Arizona Form 833
Page 2 of 5
Applicant's Name (as shown on page 1)
Super Sun Bingo APPLICATION FOR BINGO LICENSE
17 Indicate the type of premises where bingo will be played. Check one box:
a ( 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 (© 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.
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 18b Name
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
Continued on page 4>
ADOR 10334 (2/20) Arizona Form 833 Page 3 of 5
Applicant's Name (as shown on page 1)
Super Sun Bingo
APPLICATION FOR BINGO LICENSE
19 Expected bingo expenses:
a Mortgage:
$ sop month
Payable to
NIA
Address — Number and Street, Rural Rt., Apt. No.
Telephone number (with area code)
City
State ZIP Code
b Rent: $ per (J month CJ hour [J occasion
Payable to Address — Number and Street, Rural Rt., Apt. No.
N/A
Telephone number (with area code)
City
State ZIP Code
c Janitorial Services: §
per J month (hour (J occasion
Payable to
N/A
Address — Number and Street, Rural Rt., Apt. No.
Telephone number (with area code)
City
State ZIP Code
d Accounting Services: §,
per [J month (hour (7 occasion
Payable to
N/A
Address — Number and Street, Rural Rt., Apt. No.
Telephone number (with area code)
City
State ZIP Code
e Security Services: §,
per {J month CJ hour (J occasion
Payable to
N/A
Address — Number and Street, Rural Rt., Apt. No.
Telephone number (with area code)
City
State ZIP Code
f Bingo Supplies: $.200.00
, per_month
Payable to
Cactus Bingo
3210 E Roeser Rd
Address — Number and Street, Rural Rt., Apt. No.
Telephone number (with area code)
GO2- OP): BOYD
City
Phoenix
State ZIP Code
AZ 85040
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?
Cactus Bingo. No purchasing or renting of 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)
Super Sun Bingo APPLICATION FOR BINGO LICENSE
I, Kimberly Storts , 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.
~
St & IS 1IQ2 Activity Director
4!
APPLICANT'S SIGNATURE DATE TITLE
Please mail to:
Arizona Department of Revenue
1600 W Monroe Street, Division Code 22
Phoenix, AZ 85007
® (602) 716-7801
REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
(Approved (J Disapproved (ClassALicense [JClassB License (Class C License
Reviewer's Name (please print) Date License Number Effective Date Expiration Date
ADOR 10334 (2/20) Arizona Form 833 Page 5 of 5
Arizona Form
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 A.R.S. § 5-404.
Licensee's Name
SQvoaer Su Run 4O
Position {ch&ck the appropriate boxes):
fl Manager 1 Supervisor [1 Proceed Coordinator D Assistant
7
Stocks
Affidavit Bingo
License Number
REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
Affiant’s Name.
Nimberlu
mber 1)
If licensee is a qualified organization, complete the following section:
Member?
D Yes A No
Officers? Officer Title
O Yes Of No JI] Pe
Do you have an affidavit on file for any other licensee?
Dyes Ano _ If “Yes”, list license number(s):
q
Date Joined pneaton
TS NAME
1, Kim \bé. C ug Stor I Ss _____, the above-named affiant, under penalty of perjury, upon oath, depose
AFF:
and say that | will conduct
r 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. 1 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.
Signature of Aifiant
“1 [2\_) 32
Date
Please mail to:
Arizona Department of Revenue
4600 W Monroe Street, Division Code 22
Phoenix, AZ 85007
(602) 716-7801
ADOR 10327 (2/20)
Arizona Form
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 A.R.S. § 5-404,
Affidavit Bingo
Licensee's Name License Number
~ Cc .
DO DECF CUA Bina GS
Position (check the approp! te boxes):
VENUE USE ONLY, DO NOT MARK IN THIS AREA.
(J Manager upervisor oO Proceed Coordinator Oo Assistant
v
“y
[Work Phone No. (with area code)
ero te Abknod
PM a RCVD
If licensee is a qualified organization, complete the following section:
Member? Date Joined Organization
f
[Yes [XNo ALLA
Officers? Officer Title ,
Dyes Dh\o tJ L fa
Do you have an affidavit on file for any other licensee?
DyYes _EANo __If"Yes", list license number(s):
q }
tn Pit \{ , the above-named affiant, under penalty of perjury, upon oath, depose
bonduct or assis
and say that 1 Wi 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. Tam 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. a
Signature of Affiant — \_)
One Aly BAL
Date |
Please mail to:
Arizona Department of Revenue
1600 W Monroe Street, Division Code 22
Phoenix, AZ 85007
8 (602) 716-7801
ADOR 10327 (2/20)
Arizona Form
830 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 A.R.S. § 5-404.
Licensee's Name
License Number
(am) \ >.
WUpee Sun Binaa
Position (check the appropriate’boxés):
(1 Manager 1 Supervisor Wi rroceed Coordinator [CJ Assistan REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
Affiant's Name _
MARIA Le- WHITH G25 (
7 Stat Zl
PM RCVD
If licensee is a qualified organization, complete the following section:
Member? Date Joined Organization
Yes tA-No (OLA
Officers?" Officer Title
0 Yes GhNo ALLE
Do you have 4n affidavit on file for any other licensee?
O Yes If “Yes”, list license number(s):
T
1M Awe (OMe be
and say that I will conduct or assist in conducting all bingo games in compliance with the terms of the license, Arizona Revised
. the above-named affiant, under penalty of perjury, upon oath, depose
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.
67-77 -% |
Pals,
Please mail to:
Arizona Department of Revenue
1600 W Monroe Street, Division Code 22
Phoenix, AZ 85007
@ (602) 716-7801
ADOR 10327 (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
. New Application
(1 Change of Location
Date
License Number
From (Name of local governing body)
REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
Address (number and street, PO Box)
City
State
ZIP Code
Phone No. (with area code)
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:
D Application for a bingo license by the following applicant.
D1 Application for a bingo license location transfer.
2 Applicant's Name
Super Sun Bingo
3 Location/Address where live bingo will be conducted: | City State {ZIP Code
702 S. Meridian Rd. Apache Junction AZ 85120
4 Fill in the time on the days live bingo will be played:
SUN MON TUE WED THUR FRI SAT.
Olam. Olam. Olam. Oa.m. Olam. Olam. Olam.
A ,Cp.m. |e p.m. |i sOp.m. |e Op.m,}_7:00 1 Rp.m. |e Op.m.}.1:00 Kilp.m.
5 Who is your live bingo supplier?
Cactus Bingo
6 Recommendation for the application: [J Approved
0 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)