Document Text
--- Document: Amend License Document ---
LGCCC 7-A
Application to Amend
License
(Insert Bingo or Raffles)
Insert name
of Municipality
License No.
Identification No.
Prepare 4 copies. One copy will be returned
Name
of applicant
Address
1 Application is made to amend the above license as follows:
Date:
2 Additional proofs, signatures and verifications required for this amendment are attached.
3 If this amendinent is permitted, the original license will be returned in exchange for the amended
license.
(Signature of Officer)
THE STATEMENT ON THE REVERSE SIDE MUST BE SIGNED AND NOTARIZED
STATEMENT OF APPLICANT AND MEMBER(S) IN CHARGE
State of New Jersey
County of
ss.:
We do hereby each make the following statement, under oath, with respect to the original application as
amended herewith:
1 The applicant (is) (is not) limited in its
activities to the furtherance of one or more
authorized purposes as defined in the Bingo
Licensing Law or the Raffles Licensing Law.
2 Prior to the issuance of any license to it to
conduct games of chance, the applicant was
actively engaged in this State in serving one
or more "authorized purposes."
3 The applicant has received and used, and in
good faith expects to continue to receive and
use, to further one or more authorized pur-
poses, funds from sources other than games
of chance.
4 The conduct of the games on the occasion or
occasions for which this application is made
will be to raise and devote the entire net
proceeds to the authorized purpose described
in the application.
Sworn to and subscribed before me this
day of
19
Notary Public
(SEAL OF NOTARY)
5 For each occasion for which a license is
sought, one or more of the members listed
who are familiar with the Bingo Licensing
Law or the Raffles Licensing Law, as the case
may be, and the Rules and Regulations, will
be in full charge of, and primarily respon-
sible for, the conduct of the games.
6 No commission, salary, compensation, re-
ward, or recompense will be paid to any per-
son for holding, operating or conducting or
assisting in the holding, operating or con-
ducting, of the games, except to bookkeepers
or accountants for professional services not
exceeding the amounts fixed by the schedule
of Fees; no prize, premium, reward, or other
value than authorized by law will be awarded
in any single game.
7 All statements in the original application as
amended herewith are true.
Signature of Officer, and Title
Member in Charge
Member in Charge
Member in Charge
Member in Charge
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