APPLICATION FOR RAFFLE LICENSE
Organization Name: _____________________________________________________________________
Address: _____________________________________________________________________
Type of Organization: ________________________________________________________________________________
Length of Existence of Organization: ____________________________________________________________________
If organization if incorporated, what is the date and state of incorporation?
Date: ___________________________ State: ____
List the organization’s presiding officer, secretary, raffle manager and any other members responsible for the conduct and operation of the raffle.
PRESIDENT:
SECRETARY: ___________________________ Birth Date: ___________
Address: _______________________________________________________________
Social Security No. __________________________ Phone Number: _____________
RAFFLE MANAGER: _________________ Birth Date: ________________
Address: ___________________________________________________________________
Social Security No. ________________________ Phone Number: ___________
List any other members responsible for the conduct and operation of the raffle on the back of this page. List names, date of birth, address, Social Security number and phone number.
______________ The request if for a single raffle license.
______________ The request if for a multiple raffle license.
The aggregate retail value of all prizes to be awarded: $_____________________________________________________
Maximum retail value of each prize to be awarded in the raffle $______________________________________________
The maximum price charged for each raffle chance issued: __________________________________________________
The area or areas in which raffle chances will be sold or issued: ______________________________________________
________________________________________________
Time period during which raffle chances will be issued or sold: _______________________________________________
_______________________________________________
The date, time and location at which winning chances will be determined: ______________________________________
________________________________________
Date: __________ Time: _____________________
Location:___________________________________________________________
If multiple raffles license is requested, list on a separate sheet, the date, time and location for each raffle to be held within the one-year period of time from the date of the issuance of the license.
THE APPLICATION FEES ARE NONREFUNDABLE EVEN SHOULD THE APPLICATION BE REJECTED BY THE VILLAGE BOARD.
(2009 Code, Ch. 7)