Licensee:  KOFA Ko-op

Bingo License #: 14-AZ-A

Date:_____________________________________________

 

We, t
he undersigned, hereby acknowledge receipt of the amount appearing opposite our names as Bing Cash Prizes, on this date:
Name Clearly Printed Amount Won Signature
     

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NUMBER OF CARDS SOLD:_____________________       ATTENDANCE:_____________________

I have personally witnessed payment in cash of the above amounts to the individuals whose signatures appear opposite such amounts.

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Member responsible for Holding, Operating and Conducting Games