NEW HAMPSHIRE RACING AND CHARITABLE GAMING COMMISSION
21 South Fruit Street, Suite 16CONCORD, NH03301-2428
TELEPHONE: (603) 271-2158 FAX: (603) 271-3381
ADDITIONAL GAMES OF CHANCE GAME DATE INFORMATION
FOR CHARITABLE ORGANIZATIONS
Name of Charitable Organization:
Organization Phone #:Fax #:
Full Legal Address:
Street NumberStreet Name City State Zip
Full Mailing Address (Address to which all Official Correspondence shall be mailed):
Street NumberStreet Name City State Zip
Head of Organization:Title:Date of Birth:
Full Home Address:
Telephone (home): Telephone (business):
Organization Chairperson: Date of Birth:
Full Home Address:
Telephone (home):Telephone (business):
Organization Treasurer: Date of Birth:
Full Home Address:
Telephone (home): Telephone (business):
1. The charitable organization is still in good standing with the following: /Yes
/No
a)New Hampshire Secretary of State.b)New Hampshire Attorney General, Charitable Trusts Unit.
c)Internal Revenue Service (IRS).
2. The charitable organization previously submitted the following documentation (must accompany this application if not, or if no longer accurate):
a)Articles of Incorporation. / /
b)By-Laws.
3. The charitable organization has done the following:
a)Submitted a copy of this application to the chief of police in the New Hampshire city or town where games of chance will be held pursuant to RSA 287-D: 2-a.
b)Submitted a copy of this application to the New Hampshire attorney general, New Hampshire charitable trusts unit pursuant to RSA 287-D:2-a. / /
ADDITIONAL GAMES OF CHANCE GAME DATE INFORMATION
FOR CHARITABLE ORGANIZATIONS
Day / Date / Time / Treasurer or Designee / Location1. / / / / /
2. / / / / /
3. / / / / /
4. / / / / /
5. / / / / /
6. / / / / /
7. / / / / /
8. / / / / /
9. / / / / /
10. / / / / /
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Name of Game Operator (if applicable):
Address (street, city/town, zip code):
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Name of Seller or Leasor of Equipment (if applicable):
Address (street, city/town, zip code):
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Name of games of chance fnancial institution:
Games of chance account number:
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Fee: $25.00 per day X number of days = $
Make checks payable to “NH Racing and Charitable Gaming Commission” and forward to:
GAMES OF CHANCE, NH Racing and Charitable Gaming Commission, 21 South Fruit Street,
Suite 16,Concord, NH03301.
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“I certify, under the penalties of false swearing pursuant to RSA 641:2 or unsworn falsification pursuant to RSA 641:3, that the information provided on this application and in any supporting materials is accurate, only bona fide members of the charitable organization will operate games of chance, neither the applicant nor any member of the charitable organization operating the games of chance has been convicted of a felony within the previous 10 years which has not been annulled by a court, a misdemeanor involving falsehood or dishonesty within the previous 5 years which has not been annulled by a court or has violated the statutes or rules governing charitable gambling and that the applicant and any member of the organization participating in the operation of games of chance are aware of all statutes and rules applicable to the operation of games of chance.”
Signature of Authorized Official: ______Title:
Print Name: Date:
Rev. 08/2014