Bingo-Raffle Manufacturer's Agent Registration

Registration year

*This registration is for

Agent's information

*First

Middle

*Last

Suffix

Street

Must be a physical address, not a P.O. box

*Address 1

Address 2

*City

*State

*ZIP / Postal code

Province

*Country

Mailing

Address 1

Address 2

City

State

ZIP / Postal code

Province

Country

*Phone

*Email

Location of records

If agent is not located in Colorado, location of records is required.

Where are the agent's records held?

Address 1

Address 2

City

State

ZIP / Postal code

Manufacturer

*Choose the represented manufacturer.

Attachments

If applicable, you must attach:

An explanation of any conviction that occurred more than 10 years ago for a
- felony,
- theft by deception, or
- gambling-related offense.
Include details about the facts and circumstances. This applies to owners, officers, directors, partners, members, or associates.

Documents must be attached here in order to include them in your registration - documents are not accepted on paper.

You can attach .jpg, .gif, .png, or .tif image files, or PDF files.

Multiple files can be uploaded. Combined size of all files must be 4 MB or less. 1 MB = 1024 KB

Add a file

*The agent and the manufacturer or chief executive officer of the manufacturer affirm that both parties are present for the signing of this application.

Agent's signature

I solemnly affirm under penalty of perjury as defined in §18-8-503 and punishable by law that I am the applicant herein. I have read, understand, and will comply with the provisions of Title 24, Part 6, Colorado Revised Statutes (C.R.S.), also known as the Bingo and Raffles Act, with respect to supplier and manufacturer agents licenses and the conditions of the agent’s license. I further affirm that I have not been convicted of any felony, theft by deception, or gambling-related offense, as defined in Title 18, Article 10 C.R.S., within the previous ten years. I have read and know the contents of this application and the statements, attachments, and other materials included with or in it, and all matters set forth herein are true and complete.

*First

Middle

*Last

Suffix

*Address 1

Address 2

*City

*State

*ZIP / Postal code

Province

*Country

*Phone

Manufacturer's signature

*I am the

Manufacturer

Chief executive officer of the manufacturer

described in this application. As or on behalf of the manufacturer, I consent to representation by the above-named applicant.

*First

Middle

*Last

Suffix

*Address 1

Address 2

*City

*State

*ZIP / Postal code

Province

*Country

*Phone

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