Pennsylvania Eligible Organization Games of Chance Application

Eligible Organization Games of Chance Application
Eligible Organization Games of Chance Application (REV-1752)MM/DD/YYYY - Format for all Date fields

reV-1752 (AS) 05-18

For LICeNSINg AuthorIty
uSe oNLy

ELIGIBLE ORGANIZATION
GAMES OF CHANCE
APPLICATION

Please submit form to the appropriate
licensing authority.

Please Print or Type.

IMPORTANT: READ INSTRUCTIONS ON PAGE 4 BEFORE COMPLETING APPLICATION

Start

Licensing Authority

County or governing Authority Name

Phone Number

➜
Street Address

City

1. Check Appropriate Block:

Initial Application

Annual Application

State

Monthly Application

ZIP Code

Change of Data

the licensing authority must be notified of changes to the information included on this application within 15 days of the change.
2. Submit a check, cashier’s check or money order payable to the licensing authority named above for the fee due.
TYPE OF APPLICATION
FEE
EXPLANATION
game of Chance License $125.00
required for application.
$25.00

Monthly License

required for application.

➡

replacement License

Issued only if defaced, destroyed or lost. Contact the licensing authority for current fee.

3. Name of Municipality (city, borough, incorporated town or township)

4a. Liquor Identification Number (LID)

5. Indicate Type of Organization (See instructions on Page 4.)

4b. Liquor License Number (if applicable)
6.

7. Name of Organization

If incorporated, check here and attach
copy of articles of incorporation.

8. Date organization was formed

9. Location of Organization and Licensed Premises
A. Address of Normal Business or operating Site
Street Address

City

County

B. Mailing Address

Phone Number

ZIP Code

State

ZIP Code

State

ZIP Code

email Address

Check if same as 9a

Street Address

City

County

C. Licensed Premises

State

Phone Number

Check if same as 9a

Street Address

City

County

Phone Number

Licensed Premises is (check applicable box)
owned by organization

Leased by organization

owned or Leased by another licensed eligible organization and
leased to or used by the organization

other (explain):

THIS FORM MAY BE REPRODUCED
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10. A. eligible organization’s operating day
B. eligible organization’s operating week
11. As the executive officer or secretary of the eligible organization, I certify, under penalties of perjury and falsification found in
18 Pa. C.S.A. §4901 et seq., that:
A. No person under 18 years of age shall be permitted to operate or play games of chance.
B. No person who will manage, set up, supervise or participate in the operation of games of chance has been convicted of a felony, a
violation of the Bingo Law, or the Local option Small games of Chance Act.
C. the facility in which games of chance are to be played has adequate means of ingress and egress and adequate sanitary facilities
available in the area and meets all Department of health and other local or federal sanitary requirements.
D. the eligible organization is the owner of the premises upon which the games of chance are played; or, if it is not, the organization is
not leasing such premises from the owner under an oral agreement, nor is it leasing such premises from the owner under a written
agreement as a rental which is determined by the amount of receipts realized from the playing of games of chance or by the number
of people attending, except for a banquet where a per head charge is applied connecting to the serving of a meal.
E. the organization has not been convicted of a violation of the Act of Dec. 19, 1988 (P.L. 1262, No. 156), known as the Local option
games of Chance Act.
I have examined this application, including accompanying schedules and statements, and to the best of my knowledge and belief, all information provided is true, correct and accurate.
Signature of officer Preparing Application
Date of Birth
title
Date

Please sign after printing.
Print Name

Social Security Number (optional) telephone Number

12. COMMONWEALTH OF PENNSYLVANIA
COUNTY OF
Before me this day personally appeared
, who, being duly sworn
according to law, deposes and says that the statements contained in the foregoing application are true and correct.
Subscribed and sworn to before me this date:

Month

Day

year

(Seal)

Please sign after printing.
Notary Signature

My commission expires on

FALSE OR FRAUDULENT APPLICATION IS PUNISHABLE BY A FINE OF $1,000, IMPRISONMENT FOR ONE YEAR OR BOTH.
THE FOLLOWING DOCUMENTS MUST BE ATTACHED TO THE APPLICATION (use 8 1/2” X 11” sheets where possible).
1. Check, cashier’s check or money order in the amount of the total application fee payable to the licensing authority named on Page 1
of this application.
2. Schedule Sheet.
3. If incorporated, a copy of the applicant’s articles of incorporation. If not incorporated, a copy of bylaws or other legal documents that
define the organization’s structure and purposes. Documentation indicating the organization has been fulfilling its purpose for one year
prior to applying for a license is required.
4. A copy of the applicant’s Internal revenue Service tax exemption approval letter or official documentation indicating the applicant is a
non-profit charitable organization.
5. Details and copies of all written lease or rental arrangements between the applicant and the owner of premises upon which the games
of chance will be conducted, if such premises are leased or rented. If premises are owned, provide a copy of the deed.
6. each club that was required to file a games of chance report with the Department of revenue during the prior license term must attach
a copy of the report with this application.
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reV-1752 (AS) 05-18

SCHEDULE SHEET FOR ELIGIBLE
ORGANIZATION GAMES OF CHANCE
LICENSING
Please Print or Type All Information.

SCHEDULE A – Check which type(s) of games of chance the organization will conduct:
o Daily/Weekly Drawings
o Pull-tab games
o Punchboards

o race Night games

o Pools

o 50/50 Drawings

o raffles

SCHEDULE B – List the following data for all officers, directors, owners and partners. If incorporated, list all officers and shareholders
controlling 10 percent or more of outstanding stock. If organized as a partnership, list data for all partners. For all other
entities, list data of any other financially responsible person.
Full Name

Date of Birth

title or relationship

email Address