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Y <br />NOTICE OF ISSUANCE OF: <br />RAFFLE AND/OR BAZAAR LICENSE <br />CITY OR TOWN .......................... <br />Name of NM1{ori/zetl Organization <br />1, .... <br />I <br />.3�.. .... ...5.... / 5 �:. <br />Atltlress (Slreei) / Gil /Town ZIP CODE <br />F— FORM IS TO RE RETURNED TO: <br />BEANO DEPARTMENT <br />Massachusetts State Lottery <br />P.O. Box 800 <br />L BRAINTREE, MA. 02184 <br />RBL PRINT IN INK, OR TYPEWRITE <br />25M -9b3 <br />• <br />I FOR MASSACHUSETTS STATE LOTTERY COMMISSION USE ONLY I <br />OFFICIAL <br />SEAL: <br />IDENTIFICATION NUMBER DATE RECEIVED <br />COMPLETE AND SIGN THE REVERSE SIDE <br />0 <br />