Fillable Printable APPLICATION FOR RHODE ISLAND STATE POLICE
Fillable Printable APPLICATION FOR RHODE ISLAND STATE POLICE
APPLICATION FOR RHODE ISLAND STATE POLICE
RHODE ISLAND STATE POLICE
Charitable Gaming Unit
311 Danielson Pike, N. Scituate, RI 02857-1907
Telephone: (401) 444- 1147; Fax 444-1097
http://www.risp.ri.gov/sectionsandunits/charitablegaming
APPLICATION FOR CHARITABLE ORGANIZATIONS REQUESTING
GAMES OF CHANCE
$5.00 APPLICATION FEE REQUIRED (Make check or money order payable to RI State Police)
ALL APPLICATIONS, AND THE $5 APPLICATION FEE, ARE TO BE SUBMITTED TO THE LOCAL
CITY/TOWN POLICE DEPARTMENT WHERE THE DRAWING IS TO BE HELD, (with the
exception of PROVIDENCE - PROVIDENCE EVENTS ARE TO BE SUBMITTED TO THE
PROVIDENCE CITY HALL BOARD OF LICENSES.)
NAME/ADDRESS OF APPLYING ORGANIZATION_________________________________________________
___________________________________________________________________________________________________
DATE OF APPLICATION__________________ ORGANIZATION PHONE NUMBER___________________
FULL NAME, ADDRESS, ZIP CODE, BIRTH DATE, AND HOME TELEPHONE NUMBER OF
PERSON APPLYING_______________________________________________________________________________
CHECK TYPE OF LICENSE BEING REQUESTED
RAFFLE: Amt of tickets to be sold _________________ Price per Ticket_______________________
Prizes to be Awarded_____________________________________________________________________________
WEEK CLUB: # of Weeks________ Amt of tickets to be sold __________ Price per ticket_______
Prizes & Projected breakdown of expenses_______________________________________________________
___________________________________________________________________________________________________
TYPE OF ORG. APPLYING:
Religious Civic Fraternal Educational Veterans Other: _____________________
DOES ORGANIZATION HAVE STATE CHARTER AS A NON-PROFIT ORGANIZATION?____________
ADDRESS WHERE DRAWING WILL BE HELD_____________________________________________________
(Include street number, as well as name & city)
DATE(S) OF FUNCTION/DRAWING:________________________ Date Tickets will go on Sale_________
TIME OF FUNCTION/DRAWING: From_______________ To_______________
LIST DISTRIBUTION/USE OF PROCEEDS RECEIVED FROM EVENT :
(Please be specific – must be for charity/charitable purpose)
StevenG.O’Donnell
Colonel
Superintendent
LIST OF MEMBERS WHO WILL BE OPERATING, MANAGING, SUPERVISING, AND/OR RUNNING
THE GAME OF CHANCE:
NAME ADDRESS DATE OF BIRTH
__________________________________________________________________________________
* * * * * * * * * * * * * * * * * *
THE ORGANIZATION I AM REPRESENTING AND I, HEREAFTER REFERRED TO AS THE
APPLYING ORGANIZATION, AGREE TO ABIDE BY THE REGULATIONS SET FORTH BELOW AND
REALIZE THAT ANY DEVIATION FROM THESE REGULATIONS COULD RESULT IN VIOLATION
OF THE LAW AND PROSECUTION BY THE STATE OF RHODE ISLAND.
1. All games of chance will be managed, supervised, operated and controlled by permanent
members of the applying organization.
2. The services of outside promoters or persons not permanent members of the applying
organization will not be employed or used in any way in the managing, operating,
supervising or controlling of games of chance.
3. The applying organization will not allow outside promoters or persons not permanent
members of the applying organization to become members of the applying organization
for the purpose of managing, supervising, operating or controlling games of chance.
4. The applying organization will not seek the advice of outside promoters in the managing,
supervising, operating or controlling of games of chance.
5. The applying organization will not knowingly allow outside promoters on the premises
while the organization is preparing for, conducting or concluding this function involving
games of chance.
6. The aforementioned persons who are bona fide members of the applying organization and
who will be controlling, operating, supervising and managing said games of chance have
been individually and personally informed about the Rules and Regulations governing said
Games of Chance and have agreed to comply strictly with said rules.
7. It is clearly understood that within sixty (60) days after completion of this function a
complete financial report, including itemization of gross receipts, total expenses, net
profit, copies of canceled checks showing to which charity or charities the proceeds were
sent, and mail same to the Rhode Island State Police, Charitable Gaming Unit, 311
Danielson Pike, North Scituate, RI 02857.
8. Application must be submitted to the local police department at least sixty (60) days prior
to the date of function.
I hereby acknowledge that I have read, understand and will abide by the above terms and
conditions.
_______________________________________________________
FULL SIGNATURE OF APPLICANT
I DO DO NOT
RECOMMEND THE ABOVE NAMED AS A SUITABLE PERSON TO RECEIVE THIS LICENSE.
______________________________________________________
Chief of Police
_______________________________________________________
City/Town
