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0 <br />Date Organized. <br />Corporation ❑ Unincorporated Association <br />_ <br />rllan <br />Orgamza4on ❑ Educational Organization 'Civic c Organization <br />zatlon <br />Organization <br />9 <br />(non-profit)t <br />lam' <br />/ <br />Charitable` <br />Volunteer <br />Organization Other <br />u <br />Organization <br />Fire Company Fraternal <br />AUTHORIZED OFFICER OF ORGANIZATION SIGN BELOW <br />FORM S.L.C. USE ONLY <br />O TAX FORM SENT ' <br />Signawre /Zi 1 C _ <br />of9ffeer .._ .... _.... Date .... <br />_ . Il.ec Pi ,(r �A T <br />Title._l ..... <br />BY: <br />TELEPHONE gREq HOME PHONE <br />NUMBERS <br />DATE. <br />INV. ASSIGNED: <br />DATE OF OCCASION ................ <br />NUMBER OF OCCASIONS <br />NEXT TWELVE(12)MONTHS ............:'.... `....... <br />Assigned By <br />Date <br />N E OF ISSUANCE OF: <br />RAFFLE ANO/OR BAZAAR LICENSE <br />CITY OR TOWN ......................... - <br />dbA .1,4k5_ edb 6�ti-beE 13 musEurn........ ...L <br />Name of Authorized Organization <br />37? ............ <br />G2Ea NceK eA sourff .....ls�O..oaro <br />Address(Street) - - Cayfrown ZIPCODE <br />Massachusetts State Lottery <br />P.O. Box 800 <br />BRAINTREE, MA. 02184 <br />RBL PRINT IN INK, OR TYPEWRITE <br />25M -2b] <br />0 <br />I <br />FOR MASSACHUSETTS STATE LOTTERY COMMISSION USE ONLY <br />IDENTIFICATION NUMBER DATE RECEIVED <br />ql/1 7'7 <br />COMPLETE AND SIGN THE REVERSE SIDE <br />