STATE OF NEVADA GAMING CONTROL BOARD 1919 College Parkway, P.O. Box 8003, Carson City, Nevada 89702 555 E. Washington Avenue, Suite 2600, Las Vegas, Nevada 89101 3650 S. Pointe Circle Suite 203, P.O. Box 31109, Laughlin, Nevada 89028 557 W. Silver Street, Suite 207, Elko, Nevada 89801 9790 Gateway Drive, Reno, Nevada 89521 750 Pilot Road, Suite H, Las Vegas, Nevada 89119 BRIAN SANDOVAL Governor MARK A. LIPPARELLI, Chairman A.G. BURNETT, Member SHAWN R. REID, Member CHARITABLE BINGO APPLICATION FOR APPROVAL OR REGISTRATION Applicants are responsible for complying with state laws related to charitable bingo activities, specifically NRS 462 and 463. Organization Name: Street Address: City, County, Zip Code: Nature (Type) of Organization: When Organization was Established: Contact Person: Telephone: Signature: Date: By signing this application, the applicant certified that, pursuant to Nevada Statutes, the proceeds of the charitable lottery will be expended only for the benefit of charitable or nonprofit activities in the State of Nevada. Is this an application for registration or approval for a charitable lottery? (Check below.) REGISTRATION – required if the total value of all prizes offered in charitable bingo activities operated by your organization exceed $2,500 in a calendar quarter, but do not exceed $50,000 during the same calendar year. APPROVAL – required if the total value of all prizes offered in charitable bingo activities operated by your organization exceed $50,000 in a calendar quarter, but do not exceed $500,000 during the same calendar year. No application is required if the total value of prizes do not exceed $2,500. ENF-114 (Rev. 02/11) American LegalNet, Inc. www.FormsWorkFlow.com Charitable Bingo Application Page 2 Officers/Board of Directors: Name: Title: Telephone: Persons responsible for operation of the charitable bingo and their relationship to the organization (i.e., member, volunteer, employee, independent contractor, etc.): Name: Relationship to Organization: Telephone: Dates/Times/Location of Events: Description and value of charitable bingo prizes in this calendar year: If this is a request for approval, what are the anticipated expenses of conducting charitable bingos during this calendar year? Attach copies of any proposed agreements between your organization and any suppliers of material for the operation of this activity. ENF-114 (Rev. 02/11) American LegalNet, Inc. www.FormsWorkFlow.com Charitable Bingo Application Page 3 Describe the intended use of net proceeds from your charitable bingo activities during this calendar year. Indicate the approximate percentage of proceeds which will be allocated to various uses such as activities, equipment, supplies, transportation, salaries, general administrative costs, etc. Please attach the following documents: Proof of charitable or nonprofit status (such as a copy of a Nevada tax exempt certificate). Nonrefundable fee made payable to the State Gaming Control Board. ($10 for Registration/$25 for Approval Application) If you are requesting approval, copies of proposed agreements with supplies of material for the operation of charitable bingo activities. Applications must be submitted 30 days prior to the commencement of any charitable bingo activity, including advertising. Organizations are encouraged to file applications earlier than the required 30 days. Questions regarding the application process may be directed to the Board’s Enforcement Division Operations Unit in Las Vegas (702) 486-2564. Mail application and fees to: Gaming Control Board Enforcement Division Operations Unit 555 East Washington Avenue, Suite 2600 Las Vegas, Nevada 89101 Under Nevada Revised Statute 463: ♦ Qualified organizations are required to correct and submit any additional information necessary to maintain a correct and complete application with the Board. Approval of a qualified organization is suspended during the period in which any information becomes inaccurate or incomplete. ♦ Qualified organizations may not compensate any person for the prizes and supplies used in the operation of charitable bingo in the amount that exceeds their market value. ♦ Qualified organizations may not provide compensation to any person who is not a regular employee of the organization, or provide additional compensation to any regular employee for services in organizing or operation charitable bingo. ♦ Qualified organizations approved by the Chairman must submit annual financial reports concerning their activities. ♦ Registration and approval are revocable privileges. ♦ The net proceeds may only be expended for the benefit of charitable or nonprofit activities in Nevada. ENF-114 (Rev. 02/11) American LegalNet, Inc. www.FormsWorkFlow.com