REPEAL DEPARTMENT OF JUSTIC PAGE 1 of 2 MAJOR · PDF filestate of california bgc 200 (0 - . 01/2016) repeal . department of justic page 1 of 2 . major league sports raffle eligible

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STATE OF CALIFORNIA BGC 200 (0 - . 01/2016)

REPEAL DEPARTMENT OF JUSTIC

PAGE 1 of 2

MAJOR LEAGUE SPORTS RAFFLE ELIGIBLE ORGANIZATION ANNUAL REGISTRATION FORM

FOR CALENDAR YEAR 20 For Official Use Only

CT Status _________

FTB Status _________

SOS Status

MAIL TO: Burea f Gambling Control

P.O. Box 168024 Sacrament , CA 95816-8024

Phone: (916) 227-35 ; Fax: (916) 227-0170

Pursuant to California Pe I Code section 320.6, this form shall be used by eligible organizatio to apply for a registration issued by the Department o Justice. Please type or print (in ink) all information requested o his form. A nonrefundable, $5,000 Annual Registration ee must accompany this form. Make check or money o er payable to the California Department of Justice.

SECTION 1: ORGANIZATION INFORMATION

Provide at least one of the following n bers: Name of Organization

Federal Tax ID:

Corporate: Address no. and street name

Organization:

Charitable Trusts:

Zip Code

D D

Team or Association Affiliation

Is the organization qualified to conduct business in the State of California at least oneyear prior to first raffle? YES NO

City State

E-Mail Address (if applicable)

SECTION 2: TAX EXEMPT ST A TUS

Specify the organ ization's tax exempt status pursua to California Reve ue and Taxation Code section:

D 23701a D 23701b D 23701d D 23701t D 23701w

Has the organization applied for or been gran

Date of application for IRS tax exemption f exemption letter I SECTION 3: FIDUCIARY INFORMATION

(Person with legal authority to make financial decisions on behaff of the eligible organization and ensure compliance with the Major League Sports Raffle Program.)

First Name Last Name Middle Initial

D 23701 D 23701t D 23701g

OR

23701 k D 237011

ONO

Title

SECTION 4: CERTIFICATION I declare under penal of perjury under the laws of the State of California that the foregoing information, and all information submitted ·th this application itrue, correct, and c plete. I declare that our organization has been qualified to conduct business in the State of California for at least on year prior to the first raffle to be h d th is calendar year. Additionally, our organization and its representatives agree to comply with all applicable laws and ministrative regulations reg ding the conduct of major league sports raffle(s) in the State of California .

s

First Name Last Name Mi le Initial

Fiduciary's Printed Name

Fiduciary's Signature: Date:

DEPARTMENT OF JUSTIC

PAGE 2 of 2

MAJOR LEAGUE SPORTS RAFFLE ELIGIBLE ORGANIZATION ANNUAL REGISTRATION FORM

Privacy Notice on Data Collection Forms As Required by Civil Code§ 1798.17

Collection and U e of Personal Information The Division of Law nforcement, Bureau of Gambling Control in the Department Justice collects the information requested n this form as authorized by California Penal Code sectio 320.6. The Bureau uses th is information to tablish grounds for the license, permit or other appro al indicated on this application form . In additi , any personal information collected by state ag cies is subject to the limitations in the Information ractices Act and state policy. The Departm t of Justice's general privacy policy is available at http://oag.ca.gov/privacy-policy.

Providing Personal Information All the personal information requested this form must be provi ed.

Access to Your Information You may review the records maintained by tH Division of aw Enforcement, Bureau of Gambling Control in the Department of Justice that conta, your p sonal information as permitted by the Information Practices Act. (See below for contac ·nfo ation.)

Possible Disclosure of Personal Information In order to process your application , we may ne ti to sH re the information you give us with law enforcement or regulatory agencies.

The information you provide may also be ,sclosed in the follo ing circumstances:

With other persons or agencies here necessary to perfor their legal duties, and their use of your information is compatibl and complies with state law, s h has for investigations or for licensing, certification, or r ulatory purposes;

To another governme agency as required by state or federal law.

Contact Information For questions about thi notice or access to your records, you may contact the ecial Agent Supervisor of Special Programs the Department of Justice, Bureau of Gambling Control, at . 0. Box 168024, Sacramento, CA 9 816-8024, (916) 227-3584 or e-mail at Gamblin Control do·.ca. ov

http://oag.ca.gov/privacy-policy

STATE OF CALIFORNIA BGC 201 (Orig. 01/201 6)

REPEAL MAJOR LEAGUE SPORTS RAFFLE

UNPAID VOLUNTEER or INDIVIDUAL AFFILIATED PERSON ANNUAL REGISTRATION FORM

MAIL TO : FOR CALENDAR YEAR 20

DEPARTMENT OF JUSTICE

PAGE of 2

Bureau of Gambling Control P. 0. Box 168024

Sacramento, CA 95816-8024 hone: (916) 227-3584; Fax (916) 227-0170

Pursuant to Ca · ornia Penal Code section 320.6, persons affiliated with an eligible organization conducting major I ague sports raffle(s) o npaid volunteer of eligible organization or an eligible recipient organization are required to register annual with the Department o ustice. This form all be used for the registration of an individual affiliated person or unpaid volunteer of a eligible organization or a ligible recipient orga · ation for which the eligible organization has not submitted a registration application.

Please type or print (in in all information requested on this form. A nonrefundable, $10 Annual Regist tion Fee must accompany thi orm. Make check or mone order payable to the California Department of Justice.

SECTION 1: APPLICANT INFORMATION

Middle In itial Last Name Applicant's First Name

Government Issued Identification Inf mation Date of Birt (mm/dd/yyyy)

Zip Code Daytime Telephone Number Home Address (no. and street name) Ci

Zip Code Alternative Contact Telephone# Mailing Address (no. and street name) City

SECTION 2: ELIGIBLE ORGANIZATION AFFILIATION INFORMATION

Name of Eligible Organization

Eligible Organization Address (no. and street name)

Federal Tax ID Telephone Number

State Zip Code

SECTION 3: ELIGIBLE RECIPIENT ORGANIZATION INFORMATION

Name of Eligible Recipient Organizatio

Eligible Recipient Organization A clress (no. and street name) City State Zip Code

Federal Tax ID -Mail Address (if applicable) Telephone Num er

SECTION 4: CERTIFICATION I declare under penalty perjury under the laws of the State of California that the foregoing information, and all information subm ed with this appl ication , is true, correct, and com ete. I understand that the information I have provided on this form will be verified with either the eligible orga ization or the eligible recipient organizatia as part of the registration process. Additionally, I agree to comply with all applicable laws, local ordinances, and dministrative regulations conce ing major league sports raffles in the State of California.

First Name Last Name iddle Initial

Printed ame

s· nature: Date: ___________,._

STATE OF CALIFORNIA DEPARTMENT OF JUSTICE BGC 201 PAGE o/2(Orig. 01/201 6) MAJOR LEAGUE SPORTS RAFFLE

UNPAID VOLUNTEER or INDIVIDUAL AFFILIATED PERSON ANNUAL REGISTRATION FORM

Privacy Notice on Data Collection Forms As Required by Civil Code § 1798.17

Collection an Use of Personal Information The Division of L.: w Enforcement, Bureau of Gambling Control in the Department f Justice collects the information reques don this form as authorized by California Penal Code secti n 320.6. The Bureau uses this information o establish grounds for the license, permit or other appr val indicated on this application form. In ad ition, any personal information collected by state a ncies is subject to the limitations in the lnforma · n Practices Act and state policy. The Departm nt of Justice's general privacy policy is available at htt :// ov/ rivac - ol ic .

Providin ati Personal lnformAll the personal information reque ted in this form must be provid cl.

Access to Your Information You may review the records maintained y the Division of L w Enforcement, Bureau of Gambling Control in the Department of Justice that c ntain your per onal information as permitted by the Information Practices Act. (See below for c tact infor ation.)

Possible Disclosure of Personal Information In order to process your application, we may nee share the information you give us with law enforcement or regulatory agencies.

The information you provide may also be di closed in the allowing circumstances:

With other persons or agencies ere necessary to pe orm their legal duties, and their use of your information is compatible nd complies with state la , such has for investigations or for licensing, certification, or reg atory purposes;

To another government ency as required by state or federal w.

Contact Information For questions about this tice or access to your records, you may contact t e Special Agent Supervisor of Special Programs at e Department of Justice, Bureau of Gambling Contra at P. 0. Box 168024, Sacramento, CA 958 6-8024, (916) 227-3584 or e-mail at Gamblin Control d ·.ca. ov

STATE OF CALIFORNIA

BGC 202 (0 .. 01/2016)

REPEALMAJOR LEAGUE SPORTS RAFFLE

MANUFACTURER AND DISTRIBUTOR OF PRODUCTS OR SERVICES ANNUAL REGISTRATION FORM

FOR CALENDAR YEAR 20


PAGE 1 o

MAIL TO: Bureau of Gambling Control

P. 0. Box 168024 Sa amento, CA 95816-8024

Phone: (916 27-3584; Fax (916) 227-0170

Pursuant to California Pen Code section 320.6, requires manufacturers and distributors, who pr ide raffle-related products or services to eligible organ ations that conduct major league sports raffle(s) to register an ally with the Department of Justice. This form shall be use by manufacturers and distributors who provide raffle-related oducts or services to apply for registration with the Department Justice.

Please type or print (in ink) all inform tion requested on this form . A $5,000 Annual Re stration Fee must accompany this form. Make check or money order p able to the California Department of Justi

SECTION 1: ENTITY INFORMATION

Applicant's First Name Last Name Middle Initial Title

Business Name D mg Business As (if different than Business Name)

Business Address (no. and street name) City Zip Code Business Telephone Number

Mailing Address (no. and street name) City Zip Code Business Fax Number

City or County of Business License Business License Expiration Date

Federal Tax ID bsite Address (if applicable)

SECTION 2: RAFFLE-RELATED PRODUCTS AND SERVICES

Please indicate the products and/or rvices that the business provides:

D Electronic Accounting & Re orting System Software D Electronic Raffle Tic et Sales Printer

D Electronic Accounting & eporting System D Electronic Raffle Ticke aper

D Electronic Raffle Sys m Security Component D Counterfoil Container

D Electronic Raffle stem Server D Admission-style Raffle Ticket

D Electronic Ra System Server Software D Wide Area Network Component

D Electronic ffle Ticket Sales Device

Other

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STATE OF CALIFORNIA BGC 202 (0 - 01 /2016)


PAGE2 a MAJOR LEAGUE SPORTS RAFFLE


SECTION 3: MANUFACTURER LICENSE INFORMATION If additional space is needed, please attach a listing of the requested information on a separate sheet of paper.

Has the equipment be· g registered been licensed with any gaming agency, including any other state, · , county, federal, or country agency?

Yes. Please list the gaming agen and ON D license information in the follow· g table

Gaming Agency Name License Number from that Agency Expiration Date

I declare under penalty of perjury under the laws of e State of California that the foregoing information, and all information submitted with this application · tr , correct, and complete. Additionally, our business and its representatives agree to comp with a applicable laws, local ordinances, and administrative regulations concerning major I gue sports affles in the State of California.


Printed Name

Signature: ----------+----------- Date:


PAGE 3 oMAJOR LEAGUE SPORTS RAFFLE



Collection and Use f Personal Information The Division of Law E orcement, Bureau of Gambling Control in the Department f Justice collects the information requested o this form as authorized by California Penal Code secti n 320.6. The Bureau uses this information to es blish grounds for the license, permit or other appr al indicated on this application form . In addition, any personal information collected by state a ncies is subject to the limitations in the Information ctices Act and state policy. The Departm nt of Justice's general privacy policy is available at htt ://oa .c ov/ rivac - olic .

Providing Personal Information All the personal information requested · this form must be provid a.

Access to Your Information You may review the records maintained by t e Division of w Enforcement, Bureau of Gambling Control in the Department of Justice that conta· your per onal information as permitted by the Information Practices Act. (See below for conta infor ation.)

Possible Disclosure of Personal Information In order to process your application , we may nee to s are the information you give us with law enforcement or regulatory agencies.

The information you provide may also be di closed in the fol wing circumstances:

With other persons or agencies ere necessary to perfo their legal duties, and their use of your information is compatible nd complies with state law, uch has for investigations or for licensing, certification, or re latory purposes;

To another government ency as required by state or federal la

Contact Information For questions about this otice or access to your records, you may contact the pecial Agent Supervisor of Special Programs at e Department of Justice, Bureau of Gambling Control, P.O. Box 168024, Sacramento, CA 95 6-8024, (916) 227-3584 or e-mail at Gamblin Control do·. . ov

STATE OF CALIFORNIA B 203 (Orig. 01/2016)

REPEAL MAJOR LEAGUE SPORTS RAFFLE

AFFILIATED PERSON ANNUAL REGISTRATION FORM FOR CALENDAR YEAR 20

DEPARTMENT OF JUSTI

PAGE 1 12


P. 0 . Box 168024 Sacramento, CA 95816-8024

Phone. 916) 227-3584; Fax: (916)227-0170

Pursuant to California enal Code section 320.6, person(s) affiliated with an eligible organization who conduct major league sports raffle(s) must reg ter annually with the Department of Justice. This form is only for an eligibl organization to register its affiliated persons. If an dditional sheet is needed, please attach a listing of the requested infor ation on a separate sheet of paper.

Please type or print (in ink) all i ormation requested on this form. A nonrefundable $10 An ual Registration Fee for each affiliated person listed in Sectio 2 must accompany this form. Make check or mone order payable to the California Department of Justice.

SECTION 1: INFORMATION

Team or Associatio AffiliationEligible Organization

Fiduciary's First Name Last Name Middle Initial Daytime Telephone Number

Eligible Organization Address (no. and street name) Zip Code State

Mailing Address, if different (no. and street name) Zip Code State

SECTION 2: RAFFLE-RELATED DUTIES

First Name Last Name Draw Supervisor Fiduciary Raffle System Raffle Ticket Management Seller

---------

STATE OF CALIFORNIA B 203 (Orig. 011201 6)

DEPARTMENT OF JUST!

PAGE 2 12

MAJOR LEAGUE SPORTS RAFFLE AFFILIATED PERSON ANNUAL REGISTRATION FORM

SECTION 3: CERTIFICATION

I declare under pen lty of perjury under the laws of the State of California that the foregoing information, d all information submitted with this ap lication is true, correct, and complete. I understand that the information I have pr ided on this form will be verified with the igible organization as part of the registration process. I agree to comply with II applicable laws, local ordinances, and ad ·nistrative regulations concerning major league sports raffles in the State California.

Firs ame Last Name Middle Initial


Fiduciary's Signature: ---------------------/ Date:

Collection and Use of Personal lnformatio The Division of Law Enforcement, Bureau of G information requested on this form as authorized this information to establish grounds for the license, erm· or other approval indicated on this application form. In addition, any personal information collected tate agencies is subject to the limitations in the Information Practices Act and state policy. The Depa ent of Justice's general privacy policy is available at http://oag .ca. gov /privacy-policy.

Providing Personal Information All the personal information requested in this rm must be pro · ed.

Access to Your Information You may review the records maintained y the Division of Law Enforc ment, Bureau of Gambling Control in the Department of Justice that contai our personal information as per itted by the Information Practices Act. (See below for contact inform on .)

Possible Disclosure of Perso I Information In order to process your appli tion, we may need to share the information you ive us with law enforcement or regulatory agencies.

The information you pro 1de may also be disclosed in the following circumstances:

With other p sons or agencies where necessary to perform their legal duties, and eir use of your informatio s compatible and complies with state law, such has for investigations or or licensing, certificati n, or regulatory purposes;

To a ther government agency as required by state or federal law.

Contac nformation For q stions about this notice or access to your records, you may contact the Special Agent Supervis of Spe 1al Programs at the Department of Justice, Bureau of Gambling Control, at P. 0. Box 168024, S ramento, CA 95816-8024, (916) 227-3584 or e-mail at GamblingControl@doj .ca .gov

mailto:[email protected]

http://oag

STATE OF CALIFORNIA DEPARTMENT OF JUSTICE REPEAL PAGE 1 8~ 01/201 6) MAJOR LEAGUE SPORTS RAFFLE ELIGIBLE ORGANIZATION ANNUAL REPORT

PLEASE SEND COMPLETED REPORT TO: Bureau of Gambling Control P. 0. Box 168024

cramento, CA 95816-8024 Phohit: 916-227-3584; Fax (916) 227-0170

Annual Report Period:

Eligibra_,_Organization's Name: - - --------------- ------ ---,,<------

Elig ible Organization's Registration Num r:

Pursuant to Penal Code section 320.6, s division (o)(12)(A) , once registered, an eligible organiz · n shall file annually thereafter with the Department of Justice a report that incl s all of the following information for each of the e · ible organization's last three fiscal years. Pursuant to Penal Code section 320.6, subdivis· n (o)(12)(B), failure to submit the annual r ort shall be grounds for denial of an annual registration .

Year 1 Year2

to to

Year 3

to REGULATION/STATUTE

(i) The aggregate gross receipts from the operation of raffles.

(ii) The aggregate direct costs incurred by the eligible organization from the operation of raffles.

(iii) The charitable or beneficial purposes for which proceeds of the raffles were used.

(iv) The aggregate distributions of proceeds from the operation of raffles made to directly support beneficia r charitable purposes, other than beneficial or chari le purposes undertaken by the eligible organizati , or eligible recipient organizations, under Penal Code ction 320.5, subdivision (c).

(v) The aggregate distributions operation of raffles made to

(vi) The aggregate di I utions of proceeds from the operation of raffle ade to any other organizations, or for any other puq~ es, other than those included in items (ii) , (iv) , and (v bove.

STATE OF CALIFORNIA DEPARTMENT OF JUSTICE BG'6_204 (Orig. 01/2016) PAGE2MAJOR LEAGUE SPORTS RAFFLE

ELIGIBLE ORGANIZATION ANNUAL REPORT

REGULATION/STATUTE

(vii) A schedule of distrib · ns of proceeds from the operation of raffles, by indivi I raffle, made to eligible recipient organizations under Pe I Code section 320.5, subdivision (c), that are not affiliate ith the eligible organization.

(viii) A schedule of distributions of proceeds f~ the operation of raffles, by individual raffle, made to etiQ.!_ble recipient organizations under Penal Code section 32 subdivision (c) , that are affiliated with the eligible organization.

(ix) A schedule of distributions of proceeds from the operation of raffles, by individual raffle, made to any other organization not included under items (vii) or (viii) above, or for beneficial or charitable purposes undertaken by the eligible organization.

(x) The aggregate gross receipts from activities other than the operation of raffles.

(xi) The aggregate costs incurred by the eligible organization from activities other than the operation of raffles.

(xii) The aggregate distributions of funds other th proceeds from the operation of raffles made to directly s port beneficial or charitable purposes or eligibl ecipient organizations under Penal Code sectio 20.5, subdivision (c).

(xiii) The aggregate distributi s of funds other than proceeds from the operaf of raffles for purposes other than those listed in ite s (xi) and (xii) above.

Year1

to

Year 2

to

Year 3

to

STATE OF CALIFORNIA DEPARTMENT OF JUSTICE BGS.204 (Orig. 01/2016) PAGE 3 MAJOR LEAGUE SPORTS RAFFLE


REGULATION/STATUTE

(xiv) A schedule of distribution f funds other than proceeds from the operation of raffles made eligible recipient organizations under Penal Code sect1 320.5, subdivision (c), that are not affiliated with the eligible oanization .

(xv) A schedule of distributions of funds other thaA,J>roceeds from the operation of raffles made to any other orga~ation not included under item (xiv) above, or for beneficial or charitable purposes undertaken by the eligible organization.

Year1

to

Year2

to

Year3

to

NOTE: The department shall make the reports required by this ~graph_ftVailable to the public via the online search portal of the Attorney General's Registry of Charitable Trusts maintained pursuant.tO"Section 12584 of the Government Code.

CERTIFICATION

I declare under penalty of perjury under the laws of_ft(e State of California that the fore~g information is true, correct, and complete.



Date: _ __,___________Fiduciary's Signature: -----,.,<;...-----------------

STATE OF CALIFORNIA DEPARTMENT OF JUSTICE BG'&.204 (Orig. 0 1/2016) PAGE 4 ot1\MAJOR LEAGUE SPORTS RAFFLE



Collection and Use of Personal Information ' Bureau of Gambling Control in the Department of Justice collects the inf ation requested on this form

as authorized by California Penal de section 320.6. The Bureau uses this information to establish gr nds for the license, permit or other approval indicated on this applic ·on form. In addition, any personal information collected by te agencies is subject to the limitations in the Information Practices Ac d state policy. The Department of Justice's genera rivacy policy is available at http://oag. ca.gov/privacy-policy.

Providing Personal Information All the personal information requested in this form must btizprovided.

Access to Your Information You may review the records maintained by the Division of Law En~e~nt, Bureau of Gambling Control in the Department of Justice that contain your personal information as permitted by the Information P~es Act. (See below for contact information.)

Possible Disclosure of Personal Information In order to process your application, we may need to sha_J:eihe information you g~us with law enforcement or regulatory agencies.

The information you provide may also be disclose_9,1n the following circumstances:

With other persons or agencies whe_;e"necessary to perform their legal duties, and their USx of your information is compatible and complies with state law, such ha_0or investigations or for licensing, certification, or regulato~urposes;

To another government agency as required by state or federal law.

Contact Information For questions about t · notice or access to your records, you may contact the Special Agent Supervisor of Special PFQ_grams at the Department of Jus · e, Bureau of Gambling Control, at P. 0. Box 168024, Sacramento, CA 95816-8024, (916) 227-3582k>r e-mail at Gamblin Cont do·.ca. ov

http://oag

STATE OF CALIFORNIA BGC 205 (Orig. 01/2016)


PAGE of2 REPEAL

MAJOR LEAGUE SPORTS RAFFLE ELIGIBLE ORGANIZATION RAFFLE REGISTRATION FORM

FOR CALENDAR YEAR 20


P. 0 . Box 168024 Sacramento, CA 95816-8024

Phone: 916) 227-3584; Fax (916) 227-0170

Pursuant to Califor ia Penal Code section 320.6, an eligible organization that wishes to cond ct major league sports raffle(s) must gister the raffle(s) with the Department of Justice. This form is for th registration of raffle(s) for regular season and est-season home games.

Please type or print (in ink II information requested on this form . A nonrefundable 100 Registration Fee for each raffle listed in Sectio 2 must accompany this form. Make check or mon y order payable to the California Department of Jus ice.

SECTION 1: ELIGIBLE ORGANIZATION INFORMATION

Eligible Organization Team or Associati n Affiliation

Fiduciary First Name Last Name Middle Initial Daytime Telephone Number

Eligible Organization Address (no. and street name State Zip Code

Mailing Address (no. and street name) City ---State Zip Code E-Mail Address (if applicable)

SECTION 2: RAFFLE REGISTRATION

information on a separate sheet ofpaper.

rofit, Eligible Organization For Which Raffle Is Being Event Date Event Location

Conducted

,, ~'-~

1~-------------~~~---------~~~____J ~'--~~--------'-<------

.____I'----------+-------- '-----------'r------____J

.____

.____/'----_________,

/.______.________..,._________J

~!'--------,-'----'---------------'~-

~-'v------~~---------'.-----~------------.J

L----~i~' - ~-------'.-------' ---~1~1--~------~---' '------r------'/'-----1 -----'~------~

I

---------

STATE OF CALIFORNIA BGC 205 (Orig. 01/2016)

SECTION 3: CERTIFICATION

I declare under p alty of perjury under the laws of the State of California that the foregoing information, nd all information submitted with th is plication is true, correct, and complete. I understand that the information that I ha e provided on this form will be verified w h the eligible organization as part of the registration process. I agree to compl with all applicable laws, local ordinances, nd administrative regulations concerning major league sports raffles in the tate of California.


PAGE of 2

MAJOR LEAGUE SPORTS RAFFLE ELIGIBLE ORGANIZATION RAFFLE REGISTRATION FORM

F, t Name Last Name Middle Initial


Fiduciary's Signature: ---------------------- Date:

equired by Civil Code § 1 98.17

Collection and Use of Personal lnformat n The Division of Law Enforcement, Bureau of ambling Cont I in the Department of Justice collects the information requested on this form as authorize by Califo ia Penal Code section 320.6. The Bureau uses this information to establish grounds for the licen , per 1t or other approval indicated on this application form. In addition, any personal information collecte b state agencies is subject to the limitations in the Information Practices Act and state policy. The Dep ment of Justice's general privacy policy is available at http://oag .ca.gov/privacy-policy.

Providing Personal Information All the personal information requested in thi orm must be p vided.

Access to Your Information You may review the records maintaine by the Division of Law En rcement, Bureau of Gambling Control in the Department of Justice that conta· your personal information as rmitted by the Information Practices Act. (See below for contact infor tion .)

Possible Disclosure of Pers al Information In order to process your app ·cation , we may need to share the information y u give us with law enforcement or regulatory agencies.

The information you pr: vide may also be disclosed in the following circumstances.

rsons or agencies where necessary to perform their legal duties, d their use of your informati is compatible and complies with state law, such has for investigation or for licensing, certific 10n, or regulatory purposes;

To other government agency as required by state or federal law.

For estions about this notice or access to your records, you may contact the Special Agent Supe isor of cial Programs at the Department of Justice, Bureau of Gambling Control, at P. 0. Box 168024,

acramento, CA 95816-8024, (916) 227-3584 or e-mail at [email protected]

mailto:[email protected]

STAlE OF CALJFORNIA BGC 206 (Orig. 01/2016) REPEAL

MAJOR LEAGUE SPORTS RAFFLE ELIGIBLE ORGANIZATION -EQUIPMENT REGISTRATION FORM \

BUREAU OF GAMBLING CONTROL P. 0 . Box 168024 Sacramento, CA 95816-8024 Phone: (916) 227-3584; Fax: (916) 227--0170

Pursuant to Califom Penal Code section 320.6, subdivision (o)(3), an eligible organization all register the equipment used in the ale and distribution of raffle tickets, and shall have the equipment t sted by an independent gaming test laboratory. his form is used for the eligible organization to register the equi ment used in the sale and distribution of raffle tickets.

SECTION 1 - Eligible Organization Information Eligible Organization/Team or Association A iation Name:

Address (Numbers/street) City state Zip Code

Mailing Address (if different than above) City state Zip Code

Phone Number Fax Number Web Address

Fiduciary Name

Phone Number Fax Number E-Mail Address

SECTION 2 - Manufacturer License Information If additional space is needed, please attach a listing of the requested information on a separate sheet of paper.

Has the equipment being registered been · nsed with any gaming agency, includi any other state, city, county, federal, or country agency?

0No D Yes. Please list the ming agency and

license infonnation in e following table

Gaming Agency Name License Number from that Agency Expiration Date

I I

STATE OF CALIFORNIA BGC 206 (Orig. 01/2016) fl of

MAJOR LEAGUE SPORTS RAFFLE ELIGIBLE ORGANIZATION - EQUIPMENT REGISTRATION FORM \ --7

SECTION 3 - Equipment Information Complete the information below for each equipment model and its designated software version you are registering pursuant to Penal Code

section 320.6, subdivision (o)(3). If you are requesting approval for more than three pieces of equipment, please make an additional copy of this page and attach to the application.

Model Name

\ Model Number I

Software (Firmware) Version \ Sollw8n> (R'""'""' Build DalB) /

Answer the following questions r~ arding the equipment model and its designated softwarrersion (if applicable) listed above.

1. Description of equipment: I \. /

'\ /

2. Has the model and software versio~n previously tested or certified by an in7ndent gaming test DYES laboratory? If yes, attach copies of ertification documents. ONO

3. Is this equipment model leased by your ~anization? DYES ONO

4. Is this equipment model owned by your org~ ation? DYES ONO

Model Name I Model Number

(Firmware Sollw"8 (f"""8,e) v..-/ Software Build Date) \

Answer the followin~ uestions regarding the equipment model and its designated software version \

(if ap~ cable) listed above.

1. Description of~ uipment: I 2. Has the ~: and software version been previously tested or certified by an independent gaming test

laborato . If yes, attach copies of certification documents. ONOD ~

3. Is this ~ uipment model leased by your organization? ""D YEs\_o NO

4. Is/ equipment model owned by your organization? DYES ~ o

/ '\

Model Name \ ~ el Number

/\I

Software (Firmware) Version Software (Firmware Build Date)

'\ Answer the following questions regarding the equipmen_ynodel and i\_designated software version (if applicable) listed above.

1. Description of equipment: I / 2. Has the model and software version been p=sly tested or certified b~ independent gaming test

laboratory? If yes, attach copies of certifi ation DYES D NO1 documents.

3. Is this equipment model leased by your 05'anization? ""'""

DYES ONO

4. Is this equipment model owned by y/ rganization? "\ DYES O NO

I '\

STAlE OF CALIFORNIA DEPARTMENT OF BGC 206 (Orig. 01/2016)

MAJOR LEAGUE SPORTS RAFFLE ELIGIBLE ORGANIZATION -EQUIPMENT REGISTRATION FORM

SECTION 4 - CERTIFICATION/ SIGNATURE A fiduciary of the eligible organization must sign on behalf of the eligible organization.

I certify under nalty of perjury under the Jaws of the State of California that I have personally co feted this form and know that the con nts thereof, the information contained herein and in any attachments, is true, a curate, and complete. I also certify that an equipment and its designated software version indicated on this form meet the requirements of the Major League Sports ffle Program regulations and understand that the approval is subject to e following conditions:

(1) Any equipment used · the sale and distribution of raffle tickets must be from a manut. turer or distributor registered with the De rtment ofJustice, pursuant to Penal Code section 320. 6.

(2) Registration of equipmen and any associated software has no bearing on the que ion of whether the manufacturer or distributo f the device, or any person affiliated with the mantm cturer or distributor of the device, will qualify for issuan ofany registration. Any approval will be cance ed in the event that the manufacturer or distributor oft device is subsequently determined to be i Jigible for registration.

Ftduiciary's Signature


STAlE OF CALIFORNIA DEPARTJ,ENT OF BGC 206 (Orig. 01/2016)

MAJOR LEAGUE SPORTS RAFFLE ELIGIBLE ORGANIZATION -EQUIPMENT REGISTRATION FORM


Use of Personal Information The Division of w Enforcement, Bureau of Gambling Control in the Department of Ju ice collects the information reque ed on this form as authorized by California Penal Code section 3 .6. The Bureau uses this informatio to establish grounds for the license, permit or other approval i c:jicated on this application form. In a ition, any personal information collected by state agencie is subject to the limitations in the lnforma ·on Practices Act and state policy. The Department of ustice's general privacy policy is available at htt :/ a .ca. ov/ rivac - olic .

Providin Personal lnformat n All the personal information requ sled in this form must be provided.

Access to Your Information You may review the records maintaine by the Division of Law E orcement, Bureau of Gambling Control in the Department of Justice that ntain your personal · formation as permitted by the Information Practices Act. (See below for ntact informatio

Possible Disclosure of Personal lnformatio In order to process your application, we may nee re the information you give us with law enforcement or regulatory agencies.

The information you provide may also be disclos following circumstances:

· With other persons or agencies where ecessary to erform their legal duties, and their use of your information is compatible and c mplies with state w, such has for investigations or for licensing, certification, or regulate purposes;

Contact Information For questions about this notice r access to your records, you may conta the Special Agent Supervisor of Special Programs at the D artment of Justice, Bureau of Gambling Con ol, at P. 0. Box 168024, Sacramento, CA 95816-80 4, (916) 227-3584 or e-mail at Gamblin Control do·.ca. ov

Documents

REPEAL DEPARTMENT OF JUSTIC PAGE 1 of 2 MAJOR · PDF filestate of california bgc 200 (0 - . 01/2016) repeal . department of justic page 1 of 2 . major league sports raffle eligible