J Town Bingo Hall
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Santa’s Toy Chest Application:
- Bingo at J-town Bingo Hall. In-person Charitable Gaming at the Jeffersontown Bingo Hall is available Wednesday and Thursday night. Participants are required to wear a mask and complete a temperature check before entering. We must ensure compliance with all state social distancing requirements. Occupancy has been reduced. Chairs are spaced six.
- Jeffersontown Bingo Hall. 9125 Galene Dr, Louisville, KY. Bingo City At Breckenridge (1) 3441 Breckenridge Ln, Louisville, KY. Sunshine Bingo Center (6).
Please complete ALL information and return in person by *Nov. 20, 2020.
J Town Bingo Hall Louisville Ky
No late applications accepted!
Please bring in the following when turning in application:
1. Valid Florida state issued ID or Driver’s License
2. Valid Proof of Residence – Tax Bill, Lease, Voter’s Registration card are acceptable
3. Valid current utility bill
4. Proof of Income
5. Birth Certificates for any child ages 1 thru 12 in home.
*Turn in times are Monday, Tuesday, Thursday & Friday from 2pm – 6pm
Parent/Guardian Name: _____________________________________________________________
Parent/Guardian Address: ___________________________________________________________
____________________________________________________________
Parent/Guardian Phone: Home __________________ Cell__________________________________
(We must be able to contact you if application is accepted.)
Total # in Household_________
Names of those aged 1 – 12 in Home:
NameAgeM/FBirth Certificate
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Employment and Income
Employer: ______________________________
Phone #: _______________________________
Net pay total for last month: ________________
*(must provide at least 2 pay stubs within 30 days prior)
Employer: ______________________________
Phone #: _______________________________
Net pay total for last month: _______________
*(must provide at least 2 pay stubs within 30 days prior)
Anyone in home active_________ or retired military___________?
Do you or anyone in the home receive any other assistance? ________
*(please provide statement/form from any agency with amount that you or anyone in home receive)
If yes, please list below:
1) From: ______________________
Amount: ____________________
J Town Bingo Hall Schedule
2) From: ______________________
Amount: ____________________
3) From: _____________________
Amount: ____________________
If approved, preferred pick-up date and time (please check one provided)
Monday 12/14 3pm - 6pm ______
Tuesday 12/15 1pm - 4pm ______
*All information provided above must have documents to verify.
Signed: ___________________________ Date: ________________
Pick-up signature ____________________________________ Date _________________________________
__________________________________________________________________________________________
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MCC received (date): _____________ by (name): _________________________________________
J Town Bingo Louisville Kentucky
MCC copies rec’d and verified by: _____________________________________________________
J Town Bingo Phone Number
Approved: _____________ Not approved (reason): ______________________________________
Jeffersontown Bingo Hall Schedule
Applicant called by: ___________________ Pick-up day/time: _______________________________
J Town Bingo Hall
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Pick-up signature ________________________________