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NOTICE OF ISSUANCE OF: <br />SIFLE AND/OR BAZAAR LICENSE <br />oR TOWN ........................... <br />C Pt; C-cm-fr .. r <br />Name of Aulftorzatl Organization <br />N.�Ci�rr1u�}h <br />..... ..._. <br />Atltlress(Street ) �. -�-���CityR.own ..... <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 />25M4-83 <br />FOR MASSACHUSETTS STATE LOTTERY COMMISSION USE ONLY <br />IDENTIFICATION NUMBER DATE RECEIVED <br />FOR CITY/TOWN USE ONLY //}} ��T <br />Date Issued n� _" kV <br />)E Ciry/To�w � ^ ial <br />Title <br />OFFICIAL <br />SEAL: <br />COMPLETE AND SIGNTHE REVERSE SIDE <br />Date Organized <br />Corporation F]Unincorporated Association .. . <br />❑Religious <br />Organization <br />Veterans Organization <br />El (non-profit) 0 Educational Organization Civic Organization <br />Charitable- _ <br />Organization <br />❑ Volunteer - ❑ <br />Fire Company Fraternal Organization Other <br />FOR M. SL. C. USE ONLY <br />— ' 'AUTHORIZyyE��D//OFFICER O1F ORG;AN)(It1Z/An\TION SIGN BELOW <br />TAX FORM SENT <br />,,.. <br />l^\ <br />I j <br />al Offic{{e�rData .. _. <br />Title,.11/Y 1.—.WLI V.V. ✓tfG,l �!� _..... ..... ........... <br />BY <br />DATE: <br />TELEPHONE gREA HOME PHONE <br />_ NUMBERS <br />�IGNED'. <br />DATE OF OCCASION ... .:: <br />AREA TEL <br />NUMBER OF OCCASIONS Q) <br />NEXT TWELVE (12) MONTHS.Ti... ..._�.: <br />Assignetl By <br />Date <br />