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THE COMMONWEALTH OF MASSACHUSETTS <br />FEE <br />40 lii/S e <br />(city or town) <br />APPLICATION FOR PERMIT TO CONDUCT RAFFLES AND BAZAARS <br />(C. 810, ACTS OF 1969) <br />0 <br />Name and address of Nonprofit <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 />X(d) Educational or charitable organization; or, <br />❑ (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 Residence Address <br />Application certified to be in <br />conformity with C. 810, A is <br />taof 1969: <br />City/Town Cle <br />PERMIT (ISSUED) (V <br />HLLV t � . zoin <br />(date) <br />01 (t <br />City/Town ,lerk — <br />FORM 810 REV. 12/91 t�NeW 1 HOBBSB wARREN'M <br />of authory..ed officer or member of organization) <br />The Applicant (is) (is not) qualified to operate raffles and <br />bazaars under the provisions of C. 810, Acts of 69: <br />Chief of P ticc <br />OVER <br />