[DC GOVERNMENT] OLG-CharitableGamesApplication FY22-25

Section 2 of 5 in this document

MEMBERSHIP LIST

LIST TWENTY ACTIVE MEMBERS OF THE APPLICANT ORGANIZATION, (TEN IF SENIOR CITIZENS GROUP).

Member 1

Full Name

Address

Telephone Number

Member 2

Full Name

Address

Telephone Number

Member 3

Full Name

Address

Telephone Number

Member 4

Full Name

Address

Telephone Number

Member 5

Full Name

Address

Telephone Number

Member 6

Full Name

Address

Telephone Number

Member 7

Full Name

Address

Telephone Number

Member 8

Full Name

Address

Telephone Number

Member 9

Full Name

Address

Telephone Number

Member 10

Full Name

Address

Telephone Number

Member 11

Full Name

Address

Telephone Number

Member 12

Full Name

Address

Telephone Number

Member 13

Full Name

Address

Telephone Number

Member 14

Full Name

Address

Telephone Number

Member 15

Full Name

Address

Telephone Number

Member 16

Full Name

Address

Telephone Number

Member 17

Full Name

Address

Telephone Number

Member 18

Full Name

Address

Telephone Number

Member 19

Full Name

Address

Telephone Number

Member 20

Full Name

Address

Telephone Number

Section 3 of 5 in this document

PRIZE LIST

If prize is donated, submit letter from donor stating that the item is an irrevocable gift to the organization.

Item 1

Item

Retail Value

Item 2

Item

Retail Value

Item 3

Item

Retail Value

Item 4

Item

Retail Value

Item 5

Item

Retail Value

Item 6

Item

Retail Value

Item 7

Item

Retail Value

Item 8

Item

Retail Value

Item 9

Item

Retail Value

Item 10

Item

Retail Value

Section 4 of 5 in this document

ATTACHMENTS

Certificate of good standing from the D.C. Department of Consumer and Regulatory Affairs (DCRA).

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Copy of Applicants constitution articles or bylaws.

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A copy of the applicants tax exempt status (IRS or D.C. Finance and Revenue letter of determination).

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List of prizes.

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Surety Bond of Aggregated Prize Value or Provide Confirmation Letter From Donors

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Proof of use of venue ex: One of the following: Copy of Certificate of Occupancy, Copy of Rental Agreement, or Letter of Approval From Building Administrator.

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A copy of the agreement with the licensed supplier (if applicable).

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A list of games to be played at the event (if applicable).

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House rules (if applicable).

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Sample ticket (if applicable).

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Application Type

Date of Application

Organization Information

MEMBER-IN-CHARGE

Full Name

Full Address

Is the member in charge 18 years of age or older?

DEPUTY MEMBER-IN-CHARGE

Full Name

Full Address

Is the deputy member in charge 18 years of age or older?

MEMBER RESPONSIBLE FOR UTILIZATION OF GROSS RECIEPTS

Full Name

Full Address

Is the member 18 years of age or older?

CLASS OF LICENSE

RAFFLE Class of License (MARK ONE)

BINGO Class of License (MARK ONE)

MONTE CARLO Class of License (MARK ONE)

LOCATION OF EVENT

APPLICANT DETAILS

Applicant is making application as a senior citizen group.

Applicant is incorporated as a non-profit group since:

Principal activity of applicant organization

EVENT DETAILS

Date / Time of Event

Prize Information

MEMBERSHIP LIST

Member 1

Member 2

Member 3

Member 4

Member 5

Member 6

Member 7

Member 8

Member 9

Member 10

Member 11

Member 12

Member 13

Member 14

Member 15

Member 16

Member 17

Member 18

Member 19

Member 20

PRIZE LIST

Item 1

Item 2

Item 3

Item 4

Item 5

Item 6

Item 7

Item 8

Item 9

Item 10

ATTACHMENTS

Certificate of good standing from the D.C. Department of Consumer and Regulatory Affairs (DCRA).

Copy of Applicants constitution articles or bylaws.

A copy of the applicants tax exempt status (IRS or D.C. Finance and Revenue letter of determination).

List of prizes.

Surety Bond of Aggregated Prize Value or Provide Confirmation Letter From Donors

Proof of use of venue ex: One of the following: Copy of Certificate of Occupancy, Copy of Rental Agreement, or Letter of Approval From Building Administrator.

A copy of the agreement with the licensed supplier (if applicable).

A list of games to be played at the event (if applicable).

House rules (if applicable).

Sample ticket (if applicable).