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NOTICE OF ISSUANCE OF: <br />RAFFLE AND/OR BAZAAR LICENSE <br />CITY OR TOWN .......................... <br />•c, 5 (9_t1Vt5C�J.t <br />Nameel AulEorrii dOrga zalion <br />`Tb .box sgiS .. ... <br />Addres5(Street) C.Iy/.k ZIPCODE <br />F— FORM IS TO BE RETURNED TO: <br />BEANO DEPARTMENT <br />Massachusetts State Lottery <br />P.O. Box 800 <br />L BRAINTREE, MA. 02184 <br />RBL <br />25M ]A3 <br />PRINT IN INK, OR TYPEWRITE <br />I FOR MASSACHUSETTS STATE LOTTERY COMMISSION USE ONLY 1 <br />OFFICIAL <br />SEAL: <br />IDENTIFICATION NUMBER <br />IDSI.PfIs. e: 5--, v <br />City/Town Oft al <br />MJ 0 <br />Title <br />DATE RECEIVED <br />COMPLETE AND SIGN THE REVERSE SIDE <br />