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THE COMMONWEALTH OF MASSACHUSETTS <br />FEE <br />• ,V/ 51 n P /til 1� <br />city or town) <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 />2 (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 />• <br />(2) <br />(3) <br />Uses to wnfcn net proceeds will be applied: <br />Application certified to be in <br />confor .ty with C. 810, is <br />of 1969: <br />City/Townerk - <br />PERMIT (ISSUED) (DENIED) <br />November 23 2005 <br />(date) <br />Deborah F. Dami <br />City/Town Clerk <br />The Applicant (is) (is,-aet) qualified to operate raffles and <br />bazaars under the provisions o 810; Acts of 1969: <br />Chief of Police <br />FORM 810 Rev. 12/91 HhW HOBB58 WARREN OVER <br />