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NOTICE OF ISSUANCE OF: <br />RAFFLE AND/OR BAZAAR LICENSE <br />CITY OR TOWN ....................... • • l <br />Name olA aonzea Orgamzallon <br />Address lStreep Cjty1T.rr IPZIPCODE <br />USE ONLY <br />IDENTIFICATION NUMBER DATE RECEIVED <br />FOR CITY/TOWN USE ONLY <br />Dal oflssue:s <br />/Ott7t1 Cr <br />Title <br />FORM IS TO BE RETURNED TO. OFFICIAL <br />BEANO DEPARTMENT SEAL: <br />Massachusetts State Lottery <br />P.O. Box 800 <br />BRAINTREE, MA.02184 <br />RBL PRINT IN INK, OR TYPEWRITE <br />25M-]93 <br />• <br />COMPLETE -AND SIGN THE REVERSE SIDE <br />Date Organized <br />Corporation - <br />❑ Unincorporated Association <br />of OOft.,.. _I. <br />Religious <br />Organization <br />Veterans Organization <br />(non-profit) ` <br />E Educational Organization - <br />Civic Organization <br />e <br />a <br />Title... .. <br />❑ Charitable� . <br />Organization <br />F1Fire <br />Fire Company <br />Fraternal Organization <br />Other - <br />TELEPHONE <br />.AREA <br />FOR M S L.O. USE ONLY •• <br />KTAX FORM SENT <br />INV. <br />Assigned By, - Date - <br />0 <br />----APTHORIZFQ <br />OFFICER OF ORGANIZATION SIGN BELLO�OW-��n�._., <br />Signature <br />of OOft.,.. _I. <br />..... ...... .... <br />......Dale <br />.. <br />e <br />Title... .. <br />a <br />._. _..... <br />TELEPHONE <br />.AREA <br />r`HOME PHONE <br />NUMBERS <br />F5 gWAo1W9r <br />DATE OF OCCASION <br />AREA <br />BUSINESS <br />TEL. NO. <br />"NUMBER OF OCCASIONS <br />/J <br />NEXT TWELVE (12) MONTHS .... <br />..:... <br />Q <br />