Form Rcg-7 - Application For Charitable Game Supplier'S License Page 3
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1
2
3Step 5: Tell us about people in your organization and others who have an interest
in your business
(Attach additional sheets if necessary.)
1
List the following information for all persons or businesses from whom you will purchase or lease charitable game equipment or supplies.
Name_______________________________________________
Name _______________________________________________
Street address _______________________________________
Street address ________________________________________
City, state, ZIP _______________________________________
City, state, ZIP ________________________________________
Supplier’s license number _______________________________
Supplier’s license number _______________________________
2
Fill in the following information on persons not listed in Step 3 or 4 who have a direct or indirect financial, proprietary, or other interest in
your business, or who have made a loan to you or your business.
Name_______________________________________________
Name _______________________________________________
Street address _______________________________________
Street address ________________________________________
City, state, ZIP _______________________________________
City, state, ZIP ________________________________________
Social Security number __ __ __ - __ __ - __ __ __ __
Social Security number __ __ __ - __ __ - __ __ __ __
Date of birth __ __/__ __/__ __ __ __
Date of birth __ __/__ __/__ __ __ __
Month
Day
Year
Month
Day
Year
Business name _______________________________________
Business name _______________________________________
Relationship ______________
Phone (____)______________
Relationship ______________
Phone (____)______________
Nature of the interest___________________________________
Nature of the interest ___________________________________
Date interest was acquired __ __/__ __/__ __ __ __
Date interest was acquired __ __/__ __/__ __ __ __
Month
Day
Year
Month
Day
Year
Step 6: Answer the following questions
(Attach additional sheets if necessary.)
1
4
Have you, one of your employees, or anyone listed in Step 3 or
Who is responsible for furnishing records and information about
Step 5, Item 2, been convicted of a felony within the last 10 years
your business?
or a violation of the Criminal Code of 1961, Article 28 (gambling)?
Name ______________________________________________
Phone ( _____ ) __________________
yes
no
2
5
Have you, one of your employees, or anyone listed in Step 3 or
Where are your business’ books and records kept?
Step 5, Item 2, ever been a professional gambler?
Street address ________________________________________
yes
no
City, state, ZIP ________________________________________
If “yes,” please provide details. ___________________________
6
____________________________________________________
List all locations where your equipment is stored.
Street address ________________________________________
3
Do you, one of your employees, or anyone listed in Step 3 or
City, state, ZIP ________________________________________
Step 5, Item 2, have any interest, either direct or indirect, in a
licensee listed in Step 1?
Street address ________________________________________
yes
no
City, state, ZIP ________________________________________
Step 7: Sign below
Under penalties of perjury, I state that I have examined this applica-
Make your certified check or money order for $500 payable to
tion and, to the best of my knowledge, it is true, correct, and
“Illinois Department of Revenue.” Your payment must accompany
complete. I further certify that I have read and understand the
this application.
provisions of the department’s rules governing suppliers’ licenses
and licensees. In addition, I authorize Illinois Department of Rev-
Mail your application and payment to:
enue agents or employees to enter the premises of my business
during all reasonable business hours for the purpose of inspecting
OFFICE OF BINGO AND CHARITABLE GAMES
and testing all equipment and devices I offer for sale or lease.
ILLINOIS DEPARTMENT OF REVENUE
PO BOX 19480
SPRINGFIELD IL 62794-9480
President’s signature ______________________________________
Date
If you have questions, please call our Springfield office weekdays
Secretary’s signature ______________________________________
Date
between 8:00 a.m. and 4:30 p.m. at 217 524-4164. You may also
write to us at the address above.
Affix your corporate seal here.
This form is authorized as outlined by the Charitable Games Act. Disclosure of this information is REQUIRED. Failure to provide information
RCG-7 (R-7/97)
Page 3 of 3
could result in this form’s not being processed. This form has been approved by the Forms Management Center.
IL-492-2147
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