ROSATI&AMP;#X27;S PIZZA &AMP;AMP; SPORTS PUB_REDACTED.PDF

Maricopa County — Formal (2024-09-11)

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ket inctudes:

Tits Application for
» Arizona Form 833 — Applica

s Arizona Form 830 — Affidavit

Anzona Form 832 —
Endorsement by

lew a copy of the

5 advisable
é of Bingo” and the

* www.azleg gov/ and

z2S808.govipublic_s

cesitable_of_contents.him

s must be camp and legible Please iype or
1g black ink only. Forms are available in a fillable
at at Arizona Department of Revenue (ADOR)
wazdor.gov. Be sure to include on your
) a telephone number where you (or another

nsible for th as) can be reached during |

ihe day.

The bingo license package for new license and appropriate
i be sent to and approved by the local governing
city council for incorporated cities or the county
board of supervisors for unincorporated areas) prior
ia submission to the ADOR Binga S nq. Upon their
avproval or disapproval, the local governing body will
forward the license package to the ADOR Bingo Section.

body (t

Endorsement By Local Governing Body Form :
Complete lines 2, 3, and 4 of Arizona Form 832,
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/
real property to determine that such agreement
bona fide, This analysis is conducted pursuant to
RS. 5-406.F. The Bingo Section does not “approve’
é agreements as to content or other legal ramifications.
rorigly advised to consult with independent legal
to determine your rights and abligations under

If you need additional forms or have any questions, please
call the ADOR Bingo Section in Phoenix at (602) 716-7801

RECEIVED
AUG 01 2024

Cass

ration for Binge

ise Packet

CHECKLIST:

included the following

iC] Original completed Appi
(Arizona Form 833)

aL] Original completed affidavits (Arizona Form 83
Class 6 and Class C applicants must incl
complete! ffidavit for each per
inthe conduct of your gar
must include a complete affidayil for each person
particioating 48 a manager, proceeds coordinator
and supervisors.

Rantal agreement if more than one licen
the same rented premises in which to hold bingo

4] Application for Special Banus Game (Arizona Form
831) available at wwwazdorgov. If you do noi
conduct special bonus garnes do not comple
application.

sL] License fee payable to the Arizona Department of
Revenue:

aL] The local governing body fee will be payable to the
appropriate local governing entity:

Class B
Class C

7E] 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 garnes must be included on the
membership list.

a] if applying as a qualified organization, the following
must be submitted’ charter documents, articles
of incorporation, corporate bylaws, articies of
association, minutes of the establishment meeting.
and minutes of meetings for two years (bwo months of
each year) immediately prior to the date of application
for the applicant, parent and auxiliary.

aL] Purchase agreement for real property (where
applicable)

1oL] Purchase agreement/bill of sale for bingo equipment

and supplies

vi] Original local governing body endorsement.

— MARICOPA Coy;
CLERK BOARD OF SUPERVISORS

Arizona m 833 |

Application for Bingo License

If you do not, your application will be returned. Alt

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.

4 Applicant's ae

asck

US 0, zo. + pacts, Pob

Falsification of information

2a Mailing Address

Dolo LS. Anthem (soy

contained in this application
constitutes a Class 6 felony.

Ste_ A123

2b City

lancate<

DZ BHO84

State ZIP Code REVENUE USE ONLY. DO NOT MARK IN THIS AREA.

3a Administrative Office may

At lo

Lo. Anthem Loy Ste ALAS

3b City

PInaenwx%

P State ZIP Code

Az 8508

4a Name of Contact Person

solve Fowel\

5 Class B and Class C license applicants only:

organization:

(1 Charitable
C1 Fraternal

O Social

OJ Volunteer Fire Department

No.

\ea| PM RCVD

If applying as a qualified organization, check one box to indicate the type of

CJ Religious
(J Homeowners Association

OO Veterans
(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.

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

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)

ers (as shown on page

APPLICATION FOR BINGO LICENSE

ASo0ck WS Prez IPO cls Pals

Class B and Class C license applicants only: Bingo interest-bearing account information:
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.

i Ve, Cowell wModWnea wel!
Qw ner Quwner

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.

Title
Oumnec

If applying as a qualified organization, each person must be a
If additional names are required, please attach affidavits.
13b Name

iar

(Cfo ny Bushman

List the name(s) of the person(s) who will serve as supervisor.
member of the applicant. Each person must submit an affidavit.
13a Name

Jacob RPushman
Own lr

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.

N/A

Title Title

14a Name 14b Name

14¢ Name 14d Name

Street address of the PHYSICAL location where live bingo will be played:

B68 US Anthem Wouy Ste AlAB Phoenix, AZ B8508lo |

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. ae Olam. Dam. Olam. Oa.m. Olam. Oa.m.
: iC]p.m. OO p.m. iLJp.m. |. iLp.m. iC)p.m. sEJp.m. sL_]p.m.

Continued on page 3 >

ADOR 10334 (2/20)

Arizona Form 833

Page 2 of 5

Applicant's Name (as shown on page 1) Cc

sods

APPLICATION FOR BINGO LICENSE

\7ZO PL 200 chs Ff, ib

17 Indicate the type of premises where bingo will be played. Check one box:

a iM 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:

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 N/A

18b Name

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 ae page 1)

APPLICATION FOR BINGO LICENSE

asatkils 770+ Spacts Pals

19 Expected bingo expenses:

a Mortgage: $ per month