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THE COMMONWEALTH OF MASSACHUSETTS <br />FEE <br />• h I CtShnee <br />(city or lawn) <br />APPLICATION FOR PERMIT TO CONDUCT RAFFLES AND BAZAARS <br />(C. 810, ACTS OF 1969) <br />Name and address of Nonprofit Organization: <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 />(1> (cY16 <br />(I Camob-A EXPcL*ivc D(irctu- GI OCL C Vd <br />(z)C'hn,Sfin� til) ocird 41rP.�l trk c244 +S ,S+ AHi(bc�rU <br />(3) 6I l a 'Rff e I GMSUCCC lfayer C+/ 2amsl-(AH HA <br />Uses to which net proceeds will be applied: yolN'h esdUCQ'honQ I Or <br />Application certified to be in <br />con r , ity with C. 81 Acts <br />of I <br />City/Tows <br />).3 ena.. _j <br />.. , <br />r— <br />(signature of authorized 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 1969: <br />Chief of Po ce <br />OVER <br />FORM $10 Rev. 12/91 HiW HOBBSB WARREN <br />NA 0403 <br />