Raffle License Application

LGCCC 2R-A

Application for Raffles License

Application No. RA:____________

Identification No._______________

Insert name of Municipality_________________________

Prepare 4 copies of application. One copy will be returned.

Part A General

1. Name of applying organization_____________________________________________________________

______________________________________________________________________________________

2 a. Street address of headquarters___________________________________________________________

______________________________________________________________________________________

b. Mailing address (if different)_______________________________________________________________

______________________________________________________________________________________

3. A license is requested to conduct raffles of the kind stated on the date, or on each of the dates, and

during the hours listed (use a separate application for each type of raffle).

Date

Hours

Date

Hours

______________________________________________ ______________________________________________

4. Address of place where Raffles will be played_________________________________________________

______________________________________________________________________________________

a. Does the applicant own the premises or regularly occupy them for its general purposes?_________Yes_________No

5. If raffles equipment is rented, attach statement of raffles equipment lessor to application on Form 13.

Part B Qualification of Applicant

1. Is this the first time the applicant has applied for a license in this municipality?________Yes_______No

2. If not, has there been any change in the applicant’s certificate of incorporation, charter, constitution, or

by-laws since the latest application was made? __________Yes __________No

3. If applicant is unincorporated, state number of members:______________________________members.

Part B Qualification of Applicant (Continued)

4. If the answer to either of questions 1 or 2 is “Yes,” attach to this application an exact copy of the pro-

visions of the certificate of incorporation, or of the written charter, constitution or by-laws of the

applicant, showing (1) that the applicant is a qualified organization, and (2) that it is empowered to

further one or more authorized purposes, all as defined in the Raffles Licensing Law.

Part C Schedule of Expenses

The items of expense intended to be incurred or paid in connection with the games listed in this applica-

tion, the names and addresses of the persons to whom each item is to be paid, and the purpose for which

each item is to be paid are:

Item of Expense

Name & Address of Supplier

Purpose

_____________________________________________________________________________________________

Part D Schedule of Purposes

1. The specific purpose (s) to which the entire net proceeds of the games listed in this application are to

be devoted, and the manner in which they are to be so devoted are:

________________________________________________________________________

2. If any part of the net proceeds are to be devoted to a purpose allowed by the Raffles Licensing Law by

turning the same over to another organization which is exclusively devoted to such purposes, secure the

signature of its president or other executive officer to the following certificate:

“It is hereby certified that__________________________________________________________ ( Name of Organization )

will accept from the licensee any part of the net proceeds of the games listed in this application to be

turned over to it.”

Date____________________ Signature___________________________________

Part E Schedule of Prizes

A description of all prizes to be offered and given in all the games listed in this application is as follows:

(for merchandise, describe the article and state the retail value; if prizes are to be donated, so indicate

and estimate as accurately as possible the information called for.)

Description of Price

Donated (yes or no)

Retail Value

_____________________________________________________________________________________________

Part F Officers of Applicant

Office

Name of Officer

Residence Address

Age

_____________________________________________________________________________________________

Part G Member of Applicant Who Will Be in Charge of the Games

Name of Member in Charge

Residence Address

Telephone No.

Age

____________________________________________________________________________________________

(If more space is needed is any section of this application, insert extra sheets.)

Part H Members of Applicant Who Will Assist in Conduction the Games

Name of Member

Residence Address

Age

____________________________________________________________________________________________

Part I Names of Other Organizations Whose Members Will Assist in Conducting the Games

Name & Address of Organization

How Related

Identificaton Number

____________________________________________________________________________________________

Part J Statement of Applicant and Member (s) in Charge

State of New Jersey

County of } ss.:

We do hereby each make the following statement, under oath, with respect to the foregoing application:

1. The applicant (is) (is not) limited in its activi- ties to the furtherance of one or more author- ized purposes as defined in the Raffles Licen-sing Law.

5. For each occasion for which a license is sought, one or more of the members listed who are familiar with the Raffles Licensing Law, and the Rules and Regulations, will be in full charge of, and primarily responsible for, the conduct of the games.

2. Prior to the issuance of any license to it to conduct games of chance the applicant was actively engaged in serving one or more “authorized purposes.”

3. The applicant has received and used, and in good faith expects to continue to receive and use, to further one or more authorized purposes, funds from sources other than games of chance.

6. No commission, salary, compensation, reward or recompense will be paid to any person for holding, operating or conducting or assisting in the holding, operation or conducting, of the games; except to bookkeepers or accountants for professional services not exceeding the amounts fixed by the Schedule of Fees, no prize will be offered and give in cash, except as otherwise provided by the Raffles Licensing Law, or of greater value that is provided in said Law.

4. The conduct of the games on the occasion or occasions for which this application is made will be to raise and devote the entire net proceeds to the authorized purpose described in the apPlacation.

7. All statements in the foregoing application are true.

Sword to and subscribed before me this __________day of_____________20____ _________________________________ (Notary Public)	______________________________________ Signature of Officer & Title ___________________________________________ Member in Charge
(Seal of Notary)	______________________________________ Member in Charge ______________________________________ Member in Charge ______________________________________ Member in Charge

Applicant’s registration slip from the Control Commission must be presented to the Municipal Clerk with this application.