Fillable Application for a Permit to Conduct a Class (Town of Wethersfield)

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Application for a Permit to Conduct a Class (Town of Wethersfield)

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Application for a Permit to Conduct a Class 3 Bazaar
Instructions:
1. The completed form shall be submitted to:
at least fifteen (15) days prior to the start of the bazaar.
2. Applying organization must be a qualifying
non-profit functioning for a minimum of six (6) months.
3. Your application must be completed, signed, and accompanied by a check or money order made payable to
“ ” Permit Fee is $ .00 per day for up to ten (10) consecutive days.
Name of Sponsoring Organization
If this organization previously held a bazaar permit, list permit number:
Federal ID Number
IRS Exempt Status Code
Street Address
City
State
Zip Code
Mailing Address (if different than above)
City
State
Zip Code
Telephone Number (with area code)
Email Address
Contact Person for this Application
Contact Email Address
Organization Category (check only one):
An educational or charitable organization
An officially recognized organization or association of veterans
of any war in which the U. S. was engaged
A civic, service, or social club An officially recognized volunteer fire company
A fraternal or fraternal benefit society
A political party or town committee of the municipality in
which the raffle is to be held
A church or religious organization
Give the names of the three (3) Designated Active Members of the sponsoring organization under whom the bazaar
is to be conducted. These individuals will affix their signature to form CGR-1A. The three (3) Designated Active
Members must be residents of the state of Connecticut.
First Name Last Name Telephone Number (with area code) Date of Birth (mm/dd/yyyy)
First Name
Last Name
Telephone Number (with area code)
Date of Birth (mm/dd/yyyy)
First Name
Last Name
Telephone Number (with area code)
Date of Birth (mm/dd/yyyy)
Ranking Officer Name
Title
Date of Birth (mm/dd/yyyy)
Residence Street Address
City
State
Zip Code
For Official Use Only
501(c) -
Bazaar Description:
Provide the date(s) and starting and ending time(s) for each day the bazaar will be conducted:
Place Where Bazaar is to be Held:
Name of Place
Street Address
City
State
Zip Code
Types of Games and Total Number to be Operated:
Blower Ball/Cage Ball Total: _______________________ Teacup Raffle Total: _______________________
50/50
(up to 3 drawings per day)
Total: _______________________ Other: ___________________ Total: _______________________
If applicable, from whom are the games of chance equipment to be obtained:
Registered Dealer Name
Dealer Registration Number
Equipment Rental Fee Paid
List the items of expense intended to be incurred or paid in connection with the holding, operating, and conducting of
such bazaar and the names and addresses of the persons to whom, and the purposes for which, they are to be paid.
*Attach additional sheets as nec
essary.
Expense ($)
Name
Street Address
City
State
Purpose
Separately list in detail all items offered as prizes in connection with such bazaar, indicate whether or not the
items were donated, list the price to be paid by the organization or the retail value of any prize donated, and the
names and addresses of persons from whom the items were purchased or by whom donated.
*Attach additional sheets as neces
sary.
Merchandise
Donated
Yes/No
Retail
Value
Amt. Paid
by Org.
Name
Street Address
City
State
State the specific purpose to which the entire net proceeds of such bazaar are to be devoted.
I certify, under penalty of law (Sec. 53a-157b, Class A Misdemeanor), that the information provided on this
application is the truth to the best of my knowledge.
Signature of Ranking Officer
Date
Municipality Permit Fee
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Application for a Permit to Conduct a Class (Town of Wethersfield)

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Completed 17 July 2020

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