Form Dos-255 - Games Of Chance Registration - Nys Department Of State
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5NYS DEPARTMENT OF STATE
MISCELLANEOUS RECORDS UNIT
ONE COMMERCE PLAZA 99 WASHINGTON AVE.
ALBANY, NY 12231
Games of Chance Registration
(In connection with Sale of Commodities)
PLEASE READ REVERSE CAREFULLY, BEFORE FILING THIS STATEMENT.
Send this completed form and all necessary attachments to the above address along with a nonrefundable $100 filing fee.
Please make your check payable to NYS Department of State.
Attach: —Certificate of Deposit or prize monies in a trust account OR Surety Bond for total prize amount; and
—Rules and Regulations pertaining to the promotion, advertising scheme or plan.
1. NAME AND ADDRESS OF PERSON, FIRM OR CORPORATION PROPOSING TO ENGAGE IN THE GAME, CONTEST OR PROMOTION
2. GEOGRAPHIC AREA IN NEW YORK STATE COVERED BY PROMOTION
3. DESCRIPTION OF GAME, CONTEST OR PROMOTION (if not provided
(List by county, if not statewide)
by your rules and regulations)
4. TIME PERIOD COVERED BY CONTEST
8. PROPORTIONATE OPPORTUNITY OF WINNING PRIZES
BEGINNING:
ENDING:
Level of Prize
Proportionate Opportunity
5. NUMBER OF ENTRY BLANKS
TO BE MADE AVAILABLE
IN NEW YORK STATE
6. NUMBER OF PRIZE WINNING
CHANCES INCLUDED IN PLAN
IN NEW YORK STATE
7. RETAIL VALUE OF PRIZES
TO BE MADE AVAILABLE
IN NEW YORK STATE
9. NAME OF PERSON SUBMITTING FORM
RELATIONSHIP TO FIRM
ADDRESS
X
Signature
Date
REMINDER: Filing fee and specified documentation must accompany this registration statement.
DOS-255 (Rev. 4/97)
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