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NOTICE OF ISSUANCE OF: FORMASSACHUSETTS STATE LOTTERY <br />RAFFLE AND/OR BAZAAR LICENSE IDENTIFICATION NUMBER <br />CITY OR TOWN .......................... �'/ / I 7 S 7 <br />Vie: <br />JPA eHPECcw�!FfrcQEN`s ma':4Eur", <br />Name of Authorized Organization <br />i <br />Address (Street) City/Town ZIP CODE <br />F— FORM IS TO BE RETURNED T0: <br />BEANO DEPARTMENT <br />Massachusetts State Lottery <br />P.O. Box 800 FF <br />BRAINTREE, MA. 02184 <br />RBL PRINT INIINK, OR TYPEWRITE <br />35M ZA3 i <br />OFFICIAL <br />SEAL: <br />ONLY <br />DATE RECEIVED <br />Da Issue: <br />Off <br />City <br />r YLLi L1 <br />Title <br />COMPLETE AND SIGN THE REVERSE SIDE <br />