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THE COMMONWEALTH OF MASSACHUSETTS <br />FEE <br />AdshnY, Y-1 IYA <br />(city or wn) <br />APPLICATION FOR PERMIT TO CONDUCT RAFFLES AND BAZAARS <br />(C. 810, ACTS OF 1969) <br />Name and address of Nonprofit Organization: <br />Evidence of Qualification for Permit: <br />❑ (a) Veterans' organization chartered by the Congress of the United States or included in clause (12) <br />of section five of chapter forty of the General Laws; or, <br />(b) Church or religious organization; or, <br />❑ (c) Fraternal or fraternal benefit society; or, <br />❑ (d) Educational or charitable organization; or, <br />❑ (e) Civic or service club or organization; or, <br />❑ (f) Club or organization organized and operated exclusively for pleasure, recreation and other <br />nonprofit purposes, no part of the net earnings of which inures to the benefit of any member or <br />shareholder. <br />Officers or members of organization responsible for operation of raffle or bazaar: <br />Name Residence Address <br />Uses to which net proceeds will be applied:: / / <br />uI/-G d.YiG a.3/ a/11� 61,-/f]./ <br />'n4eado�s a YC We, <br />Application certified to be in <br />confor 'ty with C. 810 cts <br />of 1969: <br />City/Tow erk <br />PERMIT (ISSUED) <br />City/Town <br />The Applicant (is) (is not) qualified to operate raffles and <br />bazaars under the provisions of C. 810, Acts of 1969: <br />Chief o Police <br />OVER <br />FORM 810 REV. 12/81 H Horns& WARREN TM <br />