HomeMy WebLinkAboutBeanoFormNOTICE OF ISSUANCE OF:
RAFFLE Ao roe BAZAAR LICENSE
CITY os TOWN...................1
FOR MASSACHUSETTS STATE LOTTERY COMMISSION USE ONLY
DATE RECEIVED
I I I I I I I I I
FOR CITY/ TOWN use ONLY
Date 0f Isus:
CODE City / Town Oiclal
Tia
OFFICIAL
SEAL:
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City/Town
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CHARITABLE GAMING DEPARTMENT
Massachusetts State Lottery
P.O. Box 859012
BRAINTREE, MA 02185-9012
Address (Street)
Name of Authorized Organization
25M-7-83
Date Organized [l cororaton D Unincorporated Association
□ □ [la D □ Chaabl □ lunt D Fernl z D hegFireCompany
FOR M.S.LC. USE ONLY AUTHORIZED OFFICER OF ORGANIZATION SIGN BELOW
TAX FORM SENT Signature
of Officer ................ , •• Date
BY: Tille ... . .....
0ATE: TELEPHONc I AREA I HOME PHONE
I I I I I I I I I INV. ASSIGNED: DATE OF OCCASION •
NUMBERS
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AREA
I
HOME PHONE
I NUMBER OF OCCASIONS I I I I I I I I Assigned By Cate NEST TWELVE (12) MONTHS , .. , ....