Charitable Gaming Permit Application Questionnaire

Section 1: Organizational & Contact Information

Answer each question completely. If a question does not apply, mark “N/A.”

Organization Name(Required)

Federal Taxpayer Identification Number(Required)

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Physical Location of the Organization(Required)

Street Address Address Line 2 City State ZIP Code

Physical Location Telephone(Required)

Office/Position Title

Contact Person’s Name(Required)

First Middle Last

Fax Number

City of Physical Location(Required)

County of Physical Location(Required)

Are organizational documents attached?(Required)

Yes

Attach your Articles of Incorporation, By-Laws, etc. If 'No', explain in the next field.

If 'No', please explain

Explanation if organizational documents are not attached.

Primary Contact Email Address(Required)

Officers/Directors/Managers Listing(Required)

Provide names, addresses, and membership dates for all officers, directors, and key managers.

Section 2: Organizational History & Compliance

Has your organization been in existence and met regularly for at least three years?(Required)

Yes

If 'No', please explain where the organization has been domiciled during the past three years.

Total Number of Organization Members(Required)

Total Number of Virginia Residents (if applicable):(Required)

Contact Person for Gaming Activities(Required)

First Middle Last

Political Subdivision(Required)

Specify the City, County, or Town where your organization is primarily located.

Contact Person Telephone (Gaming Activities)(Required)

Is your organization recognized as a corporation or LLC (name as registered with Virginia State Corporation Commission)?(Required)

Yes

If 'No', please explain

Section 3: Tax Exempt Status & Federal Compliance

In the last three years, has your organization had its 501(c) status revoked or suspended?(Required)

Yes

If 'Yes', please explain

Is your organization in compliance with filing mandated Federal Returns (e.g., IRS Form 990) for the past three tax years?(Required)

Yes

If 'No', please explain

Has your organization filed the required Federal Returns?(Required)

Yes

If 'No', please explain

Is your organization in good standing with the Virginia State Corporation Commission?(Required)

Yes

Formation Date(Required)

MM slash DD slash YYYY

Section 4: Organization Type

Select the type of organization

Select the Type of Organization(Required)

Volunteer Fire Department/Emergency Medical Services

501(c)(3) Educational Organization

Athletic Association/Booster Club or Band Booster Club

Association of War Veterans or Auxiliary Unit

Fraternal Association or Corporation (Lodge System)

Organization for Older Virginians

Organization Fostering Youth Amateur Sports

Organization Providing Health Care Services/Medical Research

Accredited Public Institution/Postsecondary School

Church or Religious Organization

Organization Promoting Civic/Cultural/Moral Welfare

Organization Supporting Law-Enforcement Remembrance/Fundraising

Organization for Environmental Conservation/Science & Technology

Museum Managing Musical Heritage

Organization for Community Awareness (501(c)(7))

Organization Supporting Health (Early Detection/Research)

Local Chamber of Commerce

Other

If Other, please specify

Section 5: Charitable Gaming Activities

Which Charitable Gaming Activities will your organization conduct?(Required)

Bingo

Raffle (Standalone)

Texas Hold’em Poker Tournament

Electronic Pull-Tab/Electronic Gaming Device

Paper Instant Bingo, Seal Cards & Pull-Tabs

Annual Fundraising Event

Activity Details(Required)

For each activity, list schedule, location, and additional details. For Texas Hold’em Poker Tournaments, indicate if you will use an operator and provide operator details if applicable.

Is your organization registered with the Department to solicit charitable contributions in Virginia?(Required)

Yes

Section 6: Facility Information

Is the facility where gaming activities will be conducted leased or owned?(Required)

Leased

Owned

If Leased, provide lease details

Include the landlord’s name, address, telephone, and fax number.

Does the facility or organization hold an ABC license for conducting gaming activities?(Required)

Yes

If 'Yes', attach a copy of the ABC license and provide details

Is the facility used by more than one organization for charitable gaming?(Required)

Yes

If 'Yes', list the names of the other organizations

Section 7: Raffle-Specific Information

For standalone raffles.

Will your organization conduct a standalone raffle?(Required)

Yes

Raffle Prize Details

Provide a description of each prize, its fair market value, and indicate if the prize is purchased or donated.

Raffle Sales Information

Include the date sales begin, date/time of the drawing, ticket pricing, and volunteer/members purchase details.

Will the raffle drawing be held at a leased or owned facility?(Required)

Leased

Owned

If leased, please attach a copy of the lease and provide details

Section 8: Electronic Gaming Device / Pull-Tab Details

For electronic gaming devices, will the devices be contracted, owned, or both?(Required)

Contracted

Owned

Both

Will the devices be operated in a members-only area or a public space?(Required)

Social Quarter (members-only)

Public Space

Electronic Gaming Details

Provide details on controlled access, lease or agreement specifics, and attach a facility diagram if applicable.

Section 9: Annual Fundraising Event Details

Is your organization planning an annual fundraising event that includes charitable gaming activities?(Required)

Yes

Event Details

Provide event dates, times, gaming activities details, venue information, and ticket/sales management procedures.

Section 10: Gaming Personnel Information

Key Gaming Personnel(Required)

For each key person (e.g., President, Treasurer, Managers), provide full name, position, DOB, race/sex, SSN, home address, telephone(s), fax (if applicable), email, term of office, registration number, and relationship to the organization.

Do you consent to a background investigation for all individuals involved in gaming operations?(Required)

Yes

Identification Attachments(Required)

Max. file size: 100 MB.

Attach copies of current photo identification for each designated individual.

Section 11: Financial & Reporting Information

Financial Record Keeping(Required)

Provide the physical address and contact details for the person responsible for financial records.

Funds Disbursement(Required)

Describe how funds derived from charitable gaming will be disbursed and accounted for.

Will you file quarterly financial reports and an annual financial report?(Required)

Yes

Section 12: Disclaimer, Affidavit & Signature

Certification & Agreement(Required)

I certify that all information provided is true and accurate and I agree to abide by the applicable regulations.

Applicant’s Signature(Required)

Full Printed Name(Required)

Date(Required)

MM slash DD slash YYYY

Section 1: Organizational & Contact Information

Section 2: Organizational History & Compliance

Section 3: Tax Exempt Status & Federal Compliance

Section 4: Organization Type

Section 5: Charitable Gaming Activities

Section 6: Facility Information

Section 7: Raffle-Specific Information

Section 8: Electronic Gaming Device / Pull-Tab Details

Section 9: Annual Fundraising Event Details

Section 10: Gaming Personnel Information

Section 11: Financial & Reporting Information

Section 12: Disclaimer, Affidavit & Signature

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Made by Baljinder Bir Singh

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