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NOTICE OF ISSUANCE OF. FOR MASSACHUSETTS STATE LOTTERY COMMISSION USE OW <br />RAFFLE -AND/OR BAZAAR LICENSE IDENTIFICATION NUMBER DATERECEIVED <br />CITY OR TOWN ..........................FT1_1 <br />�.I.. F�a?�I� 1-hCics 172tUF- lipsk �� C <br />AeJre"(Streep City/Town 2 <br />Date Organized <br />❑Religious <br />Organization <br />COMPLETE AND SIGN THE REVERSE SIDE <br />Corporation U Unincorporated Association <br />Veterans Organization <br />(non-profit) 1:1 Educational Organization 1:1 Civic Organization <br />Charitable Volunteer <br />Organization 11 Fire Company �. Fraternal Organization Other <br />FOR M. S. L C. USE ONLY <br />IJ TAX FORM SENT <br />BY'. <br />DATE: <br />INV. ASSIGNED. <br />Assigned By Dale <br />0 <br />Signawre/�I7 <br />Onc <br />FORM IS TO BE RETURNED TO: <br />Tine!{2ESIDranl.,.��:Y�(z <br />BEANO DEPARTMENT <br />Massachusetts State Lottery <br />TELEPHONE <br />NUMBERS <br />P.O. Box 800 <br />rAREAF <br />BRAINTREE, MA. 02184 <br />L' I <br />RBL PRINT IN INK, OR TYPEWRITE <br />25M 7-83 <br />Date Organized <br />❑Religious <br />Organization <br />COMPLETE AND SIGN THE REVERSE SIDE <br />Corporation U Unincorporated Association <br />Veterans Organization <br />(non-profit) 1:1 Educational Organization 1:1 Civic Organization <br />Charitable Volunteer <br />Organization 11 Fire Company �. Fraternal Organization Other <br />FOR M. S. L C. USE ONLY <br />IJ TAX FORM SENT <br />BY'. <br />DATE: <br />INV. ASSIGNED. <br />Assigned By Dale <br />0 <br />Signawre/�I7 <br />Onc <br />L/.V.1.-(Il .of <br />Date <br />Tine!{2ESIDranl.,.��:Y�(z <br />TELEPHONE <br />NUMBERS <br />rAREAF <br />HOMEPHONE <br />p <br />O 4 <br />Id - <br />'\ <br />4 U <br />� � 7 <br />DATE OF OCCASION .. _.Ia.�.l�..1. ........ <br />AREA BUSINESS <br />TEL NO. <br />NUMBER OF OCCASIONS <br />s <br />8q <br />NEXT TWELVE (12) MONTHS ........! . .. <br />B <br />B <br />