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NOTICE-QoF ISSUANCE OF: <br />RAFFLE AN' D/OR BAZAAR LICENSE <br />CITY OR TOWN .......................... <br />�, vtxY m��st�vn aFCao�n� <br />aus <br />Name of AuRnmized Organization <br />Address(Street) Cily/Tme <br />F_ FORM IS TO BE RETURNED TO: <br />BEANO DEPARTMENT <br />Massachusetts State Lottery <br />P.O. Box 800 <br />L BRAINTREE, MA. 02184 <br />RBL PRINT IN INK, OR TYPEWRITE <br />25M 7 85 <br />OFFICIAL <br />SEAL: <br />IDENTIFICATION NUMBER DATE RECEIVED <br />COMPLETE AND SIGN THE REVERSE SIDE <br />Date Organized <br />Corporation ❑ Unincorporated Association <br />" <br />❑Religious <br />❑ <br />Veterans Organization ❑ ❑ <br />Organization <br />(non-profit) Educational Organization <br />Civic Organization <br />CharitableElVolunteer <br />ElOrganizatioh <br />Fire Company Fraternal Organization <br />Other <br />FOR M. S.L.C. USE ONLY <br />AUTHORIZED OFFICER OF ORGANIZATION SIGN <br />BELOW <br />❑ TAX FORM SENT <br />Signature C.,/u`(/.Y..0 A f lL � <br />of Officer L/ �/e. <br />........1, .. ........Dale <br />..� ... _.. _.. <br />By <br />p. ��Ip �eY. 1 ,(Vr <br />Title...... .✓!12t rA.,l ,y ). ............. 1 ........ <br />I <br />...... <br />DATE: <br />TELEPHONE AREA <br />NUMBERS <br />DATE OF OCCASION <br />HOME PHONE <br />INV. ASSIGNED'. <br />AREA <br />BUSINESS TEL NO <br />NUMBER OF OCCASIONS "0 O <br />NEXT TWELVE (12) MONTHS .............. <br />p <br />- / 7 a O <br />Assigned By Data <br />40 <br />