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zona 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 5-410.
1 Applicant's Name

(un 6 Taller Ryne 2 ee

2a Mailing Address contained in this application

AAwike) E. Cyache Tr. OZ constitutes a Class 6 felony.

2b City — State ZIP Code REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
Ceuche Tot. R2_ B5120
3a Administrative Office Location
Cipry CS GOy/e
3b City State ZIP Code
4a N; of Contact P ©
7] nud ey wy

4c,

PM RCVD

5 Class B and Class GC ficense applicants only: If applying as a qualified organization, check one béx to indicate the type of

organization:

0 Charitable D1 Social 1 Religious (1 Veterans

(1 Fraternal (1 Volunteer Fire Department [1] 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 RL, 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:
Pw elen Millec Teh A. A ulo

Title
Treacucer:

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)

WP imam

elrauller#Rancl

APPLICATION FOR BINGO LICENSE

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

10

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

11. 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.
ita Name . 4ib Name
| _Heler Muller _Joha & Auld
ite
LAN CCE [cheairnrun manger LtreOd Ure
42 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. ‘ Title
Helen puller menagec chairman
43 List the name(s) of the person(s) who will serve as supervisor. If applying as a qualified organization, each person must bea
member of the applicant. Each person must submit an affidavit. If additional names are required, please attach affidavits.
13a Name .-7 13b Name
Tohn K Aud
Title . Title
Qounager [t rece yer
14 List the name(s) of the person(s) who will serve as assistants. If applying as a qualified organization, each person must bea
member or new member of the applicant. Except for “Class A” licensees, each person must submit an affidavit.
14a Name 14b Name
Mone
14c Name 14d Name
145 Street address of the PHYSICAL location where live bingo will be played:
LOWS ©. APtche Trail |
46 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
Oam. “T-00 Oa.m. Oa.m. Olam. Oa.m. Oa.m. Olam.
(p.m. jp Hem. (p.m. =CIp.m. _fIp.m. [p.m Fip.m.
Continued on page 3 >
ADOR 10334 (2/20) Arizona Form 833 Page 2 of 5

a Name (as shown on page 1)

LOR

‘aT rulod Kurc

APPLICATION FOR BINGO LICENSE

47 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

Dot rented bs lecbed

Address — Number and Street, Rural Rt, Apt. No.

Telephone Number (with area code)

State ZIP Code

City

c Owned solely by the organization. Attach copy of mortgage, deed of trust, purchase agreement, escrow agreement, or

other related document:
Holder of Mortgage 0 2 [Address — Number and Street, Rural Rt, Apt. No.
Telephone Number (with area code) City State ZIP Code

d (9 Owned jointly with other organization. Attach copy of mortgage, deed of trust, purchase agreement, escrow agreement, or

other related document:

1) Holder of Mortgage

£IA¢

[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

48 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:

le

18a Name e ( om)

18b Name

Tin &. Auld

|
te

Continued on page 4 >

ADOR 10334 (2/20)

Arizona Form 833

Page 3 ofS

ee ‘on page 1) ?
LXIR« '4Troller Karch APPLICATION FOR BINGO LICENSE

19 Expected bingo expenses:

your live bingo games?

sone,

Telephone number (with area code)

Mortgage: per month
Payable to |Address — Number and Street, Rural Rt., Apt. No.
‘Telephone number (with area code) City State ZIP Code
Rent: sl BY 22 per month (hour (© occasion
Payable to Address — Number and Street, Rural RL, Apt. No.
Telephone number (with area code) City State ZIP Code
Janitorial Services: s NOR, per( month (hour © occasion
Payable to [Address — Number and Street, Rural Rt, Apt. No.
‘Telephone number (with area code) City State ZIP Code
Accounting Services: $, Ax Ne per(J month (hour [7 occasion
Payable to Address — Number and Street, Rural Rt, Apt. No.
‘Telephone number (with area code) City State ZIP Code
Security Services: $ NOM... perO month Chour GB occasion
Payable to Address — Number and Street, Rural Rt., Apt. No.
Telephone number (with area code) City State ZIP Code
[Address — Number and Street, Rural Rt, Apt. No.
City State ZIP Code

? I bingo supplies). Do you foresee purchasing/renting machines as “technological aids for

£0

Continued on page 5 >

ADOR 10334 (2/20)

Arizona Form

833

Page 4 of 5

Applicant's Name (as shown on page 1)

Dirt 5b Traded 4a Yard APPLICATION FOR BINGO LICENSE
1, Nth Feithes , under penalty of perjury and upon oath, declare that I am duly authorized to sign

and file this applicatien. 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.

Loathagh

b9- dB 29 me) Wa

APPLICANT'S SIGNATURE
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 EI Disapproved CIClassALicense [IClassBLicense [Class C License

Reviewer's Name (please print) Date License Number Effective Date Expiration Date

ADOR 10334 (2/20) Arizona Form 833 Page 50f5

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 License Number

Affidavit Bingo

Position (check the appropriate boxes):

[1] Manager __[] Supervisor [1] Proceed Coordinator {91 Assistant REVENUE USE ONLY. DO NOT MARK IN THIS AREA.

Affiant’s “ent in few VM : ( bey -

Social Security Number

RCVD

ne No. (with area code)

If licensee is a qualified organization, complete the following section:

Member? Date Joined Organization
OlYes [EINo

Officers? Officer Title

Dyes [No

Do you have an affidavit on file for any other licensee?
ElYes  [INo _if “Yes”, list license number(s):

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.

~~

Abbe

\-Signature of Affiant

DRecember 8, 2023

Date

Please mail to:
Arizona Department of Revenue
1600 W Monroe Street, Division Code 22
Phoenix, AZ 85007

B (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.

Licensee's Name License Number

Affidavit Bingo

Position (check the appropriate boxes):

Oo Manager (2) Supervisor _[[] Proceed Coordinator Assistant REVENUE USE ONLY. DO NOT MARK IN THIS AREA.

MmanisName oh wt A, Auk

Social Security Number :

PM RCVD

Hi " Work Phone No. (withafea code)
Ut

If licensee is a qualified organization, complete the following section:

Member? Date Joined Organization
DlYes_ [INo

Officers? Officer Title

Dyes [No

Do you have an affidavit on file for any other licensee?
DiYes_[IJNo _ if “Yes”, list license number(s):

—
I, wi é /; th WA VA . Al Y LD , the above-named affiant, under penalty of perjury, upon oath, depose

AEFIANT'S NAME
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.

Signature of Affiant”

/L-~/6- 1043

Date

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 TOA.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.
AR.S. §§ 5-409 and 5-410

. Date License Number
4A New Application (3 Change of Location
From, (Name of local governing ly)
th va REVENUE USE ONLY. DO NOT MARK IN THIS AREA.
Address (number and t, PO Box)
City State ZIP Code

Phone No. (with area code)

PM i" 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.
(1 Application for a bingo license location transfer.

2 Applicant's Name  DOIRG ‘4 TO ie- Rirrb

3  Location/Address where live bingo will be conducted; | Ci —— Ss ZIP Code
lOTio €. Opreheirty! ocche Tet FA2 FaS%co0

t

4 Fillin the time on the days live bingo will be played:

SUN MON TUE WED THUR FRI SAT
Olam. WAG.) Oa.m. Olam, Olam. Olam. Olam. Olam,
Cp.m. em. _.CIp.m. p.m. p.m. Op... Clp.m.

5 Who is your live bingo supplier?
Mone

6 Recommendation for the application: [] Approved [J 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

4600 W Monroe Street, Division Code 22
Phoenix, AZ 85007

& (602) 716-7801

ADOR 10326 (2/20)

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