Form Center

2. Name of Applicant
4. Address of Applicant
6. City
7. State
8. Zip Code
10. Type of Organization
12. Name of Designated Raffle Manager Responsible for the Conduct and Reporting of the Raffle
14. Address of Raffle Manager
16. City
17. State
18. Zip Code
20. Name or Number Designation of This Specific Raffle
22. Aggregate Value of All Prizes Awarded by the License Under This Raffle
24. The maximum retail value of each prize under this raffle is as follows:
25. The maximum price to be charged for each ticket under this raffle is as follows:
27. Area Within City in Which Raffle Chances Will Be Sold
28. The Maximum Time Period on Which Raffle Chances Will Be Sold
30. The Time of Determination of Winning Chances
31. Location at Which Winning Chances Will Be Determined
33. Applicant is a bona fide religious, charitable, labor, business, fraternal, educational or veterans organization that operates without profit to their members and which have been in existence continuously for a period of 5 years immediately before making application for a license and which have had during that 5 year period a bona fide membership engaged in carrying out their objectives.
35. The undersigned, under penalties or perjury, hereby states that the above information is true and correct.
37. Electronic Signature

    Type Full Name

39. Secretary / Attesting Officer Acknowledgement

    1. Yes
    2. No
40. President / Presiding Officer Acknowledgement

    1. Yes
    2. No
42. A $10 fee, payable to the City of Litchfield, must accompany each application.
44. Name
    Fee
45. Price
46. Quantity
47. Shipping Cost
49. Taxable
Leave This Blank:


50. Calculate Totals Proceed to Checkout

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