STATEMENT OF ACTIVE MEMBERS DESIGNATED BY SPONSORING
ORGANIZATION UNDER WHOM THE RAFFLE IS TO BE HELD, OPERATED OR
We, the undersigned, do hereby EACH make the following statement under the penalty of False Statement with
respect to the foregoing application:
1. I am a resident of the state of Connecticut.
2. I am a bona fide active member of the sponsoring organization making this application to conduct a raffle and
all statements contained in this application are true to the best of my knowledge and belief.
I will be responsible for the holding, operation and conduct of such raffle in accordance with the terms of the
permit, the provisions of the A
ct, and regulations.
4. I have never been convicted of a felony.
5. I am familiar with the provisions of the Act which PROHIBIT:
The giving of cash prizes, except with an approved “Class No. 1”, “Class No. 2”, “Class No. 4”, cow-chip,
duck-race, golf ball drop (“Class No. 6” only), or frog-race raffle permit.
b. The giving of alcoholic beverages as prizes.
c. The giving of prizes redeemable for cash.
d. The paying of commission, salary, compensation, reward or recompense, directly or indirectly, to any
person holding, operating, conducting or assisting therein in the operation of a raffle.
e. The promotion or operation of a raffle by other than duly qualified members of the sponsoring
f. The giving of pay to any member for his time or effort in connection with a raffle.
g. The promotion, conduct or operation of a raffle by a person under the age of 18 or the permitting of same
by the sponsoring organization.
h. The selling or promoting of the sale of raffle tickets by persons under the age of 16 years, or the
permitting of the same by the sponsoring organization.
i. The use of funds derived from the raffle for purposes other than as stated in this application.
j. The paying of any monies except in reasonable amounts for goods, wares and merchandise furnished or
services rendered which are necessary for the operation of a raffle.
6. I am familiar with the provisions of the Act which:
a. Provide that each raffle ticket shall have printed thereon the time, date and place of the raffle, the three
most valuable prizes to be awarded and the total number of prizes to be awarded.
b. Require all proceeds from cash prize raffles to be deposited in a special checking account established and
maintained by the sponsoring organization, and all raffle expenses and cash prizes awarded shall be paid
from such account.
Require all proceeds from special tuition raffles to be deposited in an approved dedicated bank account
and all raffle expenses s
hall be paid from such account.
d. Make mandatory the immediate revocation of a permit to conduct a raffle for a violation of the provisions
of the Bazaar or Raffle Act, and which provide that an organization whose permit has been revoked for a
violation shall not be granted another permit for a period of three years.
e. Provide a fine of not more than one thousand dollars or imprisonment for not more than one year or both
for a violation of the Act.
PRINTED NAMES AND SIGNATURES OF DESIGNATED ACTIVE MEMBERS: