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NOTIG•E OF ISSUANCE =OF: OF:, <br />AND/OR BAZAAR LICENSE LL� <br />CITY OR TOWN .......................... <br />Name of Authorized Organization <br />Address (Street) _.. - � •. Cityrto n ' ZIPCODE <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 IE3 <br />IDENTIFICATION NUMBER I DATE RECEIVED <br />OFFICIAL <br />SEAL: <br />COMPLETE AND SIGN THE REVERSE SIDE <br />-''- Date Organized <br />❑ Corporation ❑ unincorporated Association <br />.-. , <br />- <br />Religious <br />�I <br />."w, <br />Veterans Organiiatfon <br />El Organ¢ahon <br />Crolc Organization <br />Organization <br />L—J <br />(non-profit) Educational <br />` ❑Charitable <br />❑ <br />Volunteer' -` <br />Fraternal Organization ❑ <br />Other <br />. organization <br />Fire Company <br />FOR M.S. L.C. USE ONLY.:. <br />- <br />AUTHORIZED OFFICER OPORGANIZATION SIGN BELOW <br />❑TAS FORM SENT <br />. - <br />Si nature <br />�.. � .... <br />,� <br />Of OffDicer .. ../�_..1... .........Date <br />BY: <br />Title .......... ........ ....... n <br />........... <br />DATES <br />TELEPHONEAREAHOMEPHONE <br />NUMBERS <br />INV. ASSIGNED: <br />DATE OF OCCASION ............ . <br />AREA <br />BUSINESS TEL NO. <br />NUMBER OF OCCASIONS <br />NEXT TWELVE (12) MONTHS .. _....... �....:.:.... <br />Assigned By Date <br />• <br />