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Business License 38250 Sierra Highway Palmdale, CA 93550 661/247-8384 661/267-5434 [EMAIL REDACTED] [EMAIL REDACTED] Page 1 of 3 Bingo Business Permit Application REV. 10/11/22 BINGO PERMIT APPLICATION This Application is for (check one) New Permit Annual Renewal Business Name: (If a Corporation, the name shall be as set forth in its Articles of Incorporation) Business Address: Business Telephone number and Email: If a corporation, the names and addresses of all directors, any stockholder holding 10% or more of the shares, and the name and address of an officer who is duly authorized to accept service of legal process. If the applicant is a partnership, the names, addresses and telephone numbers of each general partner. If one of the partners is a corporation, see above requirements. List the nature of the organization and a statement that the applicant is an eligible organization as defined by PMC Section 5.04.430:2: Please list the exact location and occupancy capacity where Bingo games are proposed to be held (list if the maximum number of players at any one time will be more than 100): Bingo game day of the week and hours: The name(s), home addresses and telephone numbers of the person(s) directly responsible for operation of the Bingo games (Bingo Managers) and date they became members of the organization (Indicate who are callers or assistant callers): Description of the record system to account for receipts, prizes, expenses and profits of each Bingo game: The location and signatories of the bank account required by this section: List the specific charitable purposes which the proceeds will benefit: ---PAGE BREAK--- Business License 38250 Sierra Highway Palmdale, CA 93550 661/247-8384 661/267-5434 [EMAIL REDACTED] [EMAIL REDACTED] Page 2 of 3 Bingo Business Permit Application REV. 10/11/22 1. Permittee must within five days notify this office in writing of any change in any fact required by this application. 2. Permittee shall notify the director of any changes in the list of members who will operate or staff Bingo games. All notifications must be in writing. 3. Attached to this application and on file with the City of Palmdale must be a true and correct copy of exemption letter and fingerprints of all staff of Bingo games. 4. The undersigned agree to conduct Bingo games in strict accordance with the provisions of Section 326.5 of the California Penal Code and the Palmdale Municipal Code as they may be amended from time to time, and agree that the permit to conduct Bingo games may be revoked upon violation of any such provisions. WE CERTIFY UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE INFORMATION CONTAINED HEREIN IS TRUE AND CORRECT. AS A CONDITION FOR THE ISSUANCE OF THE PERMIT APPLIED FOR, WE AGREE TO SUBMIT ANY ADDITIONAL INFORMATION THAT MAY BE REQUIRED TO CONDUCT ALL PHASES OF THE BUSINESS IN ACCORDANCE WITH ALL APPLICABLE LAWS, ORDINANCES AND REGULATIONS FOR SUCH BUSINESS, AND TO MAINTAIN ALL EQUIPMENT THAT MAY BE USED IN CONNECTION THEREWITH IN CONFORMANCE WITH ALL APPLICABLE LAWS, ORDINANCES AND REGULATIONS. Officer’s Signature Title Date Officer’s Signature Title Date (Signatures of two presiding officers required) AND/OR Trustee Signature Date ---PAGE BREAK--- Business License 38250 Sierra Highway Palmdale, CA 93550 661/247-8384 661/267-5434 [EMAIL REDACTED] [EMAIL REDACTED] Page 3 of 3 Bingo Business Permit Application REV. 10/11/22 OFFICE USE ONLY Recommend ( ) Not Recommended ( ) Los Angeles County Sheriff’s Department: Signature Date Planning Manager: Signature Date