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THE COMMONWEALTH OF MASSACHUSETTS <br />•(city or town) FEE <br />• <br />APPLICATION FOR PERMIT TO CONDUCT RAFFLES AND BAZAARS <br />(C. 810, ACTS OF 1969) <br />Name and address of <br />IL. <br />• ' f1 s • • ' <br />Evidence of Qualification for Permit: <br />❑ (a) Veterans' organization chartered by the Congress of the United States or included in clause (12) <br />of section five of chapter forty of the General Laws; or, <br />❑ (b) Church or religious organization; or, <br />❑ (c) Fraternal or fraternal benefit society; or, <br />❑� /(d) Educational or charitable organization; or, <br />LW (e) Civic or service club or organization; or, <br />❑ (f) Club or organization organized and operated exclusively for pleasure, recreation and other <br />nonprofit purposes, no part of the net earnings of which inures to the benefit of any member or <br />shareholder. <br />Officers or members of organization responsible for operation of raffle or bazaar: <br />Name <br />Residence Address <br />Uses to which net proceeds will be applied: <br />Application certified to be in <br />conformity with C. 810 Acts <br />of 1969: <br />City/Town e <br />FORM 810 Rev. 12/91 H&W Horus&WARREN TM <br />of authorized officer ohfiernber of organization) <br />The Applicant (is) (is not) qualified to operate raffles and <br />bazaars under the provisions of C. 810, Acts of 1969: <br />F( of of Pol e %a—zl <br />OVER <br />movXV\ <br />rn o'vh <br />