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NOTICE OF ISSUANCE OF: <br />RAFFLE AND/OR BAZAAR LICENSE <br />CITY OR TOWN .......................... I 1 <br />Name of Aulhorizetl Organ zwil <br />Atltlress (Sueep CiryRown <br />F— FORM IS TO BE RETURNED TO. <br />BEANO DEPARTMENT <br />Massachusetts State Lottery <br />P.O. Box 800 <br />BRAINTREE, MA. 02184 <br />RBL PRINT IN INK, OR TYPEWRITE <br />25M l 83 <br />0 <br />I <br />OFFICIAL <br />SEAL: <br />USE ONLY <br />IDENTIFICATION NUMBER DATE RECEIVED <br />Dale flssue: <br />Ciryrto oiselaL <br />Titin Oki <br />Title <br />COMPLETE AND SIGN THE REVERSE SIDE <br />