Application No. RA _________________
Identication No. __________________
Application for a Rafes License
Submit four (4) copies of this application to the Municipal Clerk’s ofce in the municipality where the games will be conducted.
Please print clearly.
Name of municipality: ____________________________________________________________________________________
Part A - General
1. Name of applying organization: _________________________________________________________________________
2a. Street address of headquarters: __________________________________________________________________________
b. Mailing address (if different):
3. A license is requested to conduct rafes 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 rafe).
Date Hours Date Hours
____________________________ __________ ____________________________ __________
____________________________ __________ ____________________________ __________
____________________________ __________ ____________________________ __________
____________________________ __________ ____________________________ __________
____________________________ __________ ____________________________ __________
____________________________ __________ ____________________________ __________
____________________________ __________ ____________________________ __________
4a. Address of place where rafes will be played:
b. Does the applicant own the premises or regularly occupy them for its general purposes? Yes No
5. If rafes equipment is to be rented, attach a statement by the rafes equipment lessor to this application on Form 13.
Part B - Schedule of Expenses
The items of expense intended to be incurred or paid in connection with the games listed in this application, 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 and address of supplier Purpose
__________________________ ________________________________________________ ________________________
__________________________ ________________________________________________ ________________________
__________________________ ________________________________________________ ________________________
__________________________ ________________________________________________ ________________________
__________________________ ________________________________________________ ________________________
__________________________ ________________________________________________ ________________________
__________________________ ________________________________________________ ________________________
__________________________ ________________________________________________ ________________________
__________________________ ________________________________________________ ________________________
__________________________ ________________________________________________ ________________________
__________________________ ________________________________________________ ________________________
__________________________ ________________________________________________ ________________________
__________________________ ________________________________________________ ________________________
__________________________ ________________________________________________ ________________________
__________________________ ________________________________________________ ________________________
__________________________ ________________________________________________ ________________________
Part C - Schedule of Purposes
1. The specic 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 Rafes 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 ofcer to the following certicate:
“It is hereby certied 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 D - Schedule of Prizes
A description of all prizes to be offered and given in all of 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, indicate that fact and estimate as accurately as pos-
sible the information requested below.
Description of Prize Donated (Yes or No) Retail value
_______________________________________________________ Yes No __________________________
_______________________________________________________ Yes No __________________________
_______________________________________________________ Yes No __________________________
_______________________________________________________ Yes No __________________________
_______________________________________________________ Yes No __________________________
_______________________________________________________ Yes No __________________________
_______________________________________________________ Yes No __________________________
_______________________________________________________ Yes No __________________________
_______________________________________________________ Yes No __________________________
_______________________________________________________ Yes No __________________________
_______________________________________________________ Yes No __________________________
_______________________________________________________ Yes No __________________________
_______________________________________________________ Yes No __________________________
_______________________________________________________ Yes No __________________________
_______________________________________________________ Yes No __________________________
_______________________________________________________ Yes No __________________________
_______________________________________________________ Yes No __________________________
_______________________________________________________ Yes No __________________________
_______________________________________________________ Yes No __________________________
_______________________________________________________ Yes No __________________________
_______________________________________________________ Yes No __________________________
_______________________________________________________ Yes No __________________________
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Part E - Ofcers of Applicant
Ofce Name of ofcer Residence address Age
__________________________ _______________________________ _____________________________________ _____
__________________________ _______________________________ _____________________________________ _____
__________________________ _______________________________ _____________________________________ _____
__________________________ _______________________________ _____________________________________ _____
__________________________ _______________________________ _____________________________________ _____
Part F - Members of Applicant who will be in charge of the games
Name of member in charge Residence address Telephone No. Age
(include area code)
_____________________________ _________________________________________ ________________________ _____
_____________________________ _________________________________________ ________________________ _____
_____________________________ _________________________________________ ________________________ _____
_____________________________ _________________________________________ ________________________ _____
_____________________________ _________________________________________ ________________________ _____
Part G - Members of Applicant who will assist in conducting the games
Name of member Residence address Age
________________________________________ ________________________________________________________ _____
________________________________________ ________________________________________________________ _____
________________________________________ ________________________________________________________ _____
________________________________________ ________________________________________________________ _____
Part H - Names of other organizations whose members will assist in conducting the games
Name and address of organization How related Identication No.
______________________________________________________ ___________________________ ____________________
______________________________________________________ ___________________________ ____________________
______________________________________________________ ___________________________ ____________________
continue
If more space is needed in any section of this application, insert extra sheets of paper.
Part I - Statement of Applicant and member(s) in charge
State of New Jersey
County of __________________________________
We do hereby each make the following statement, under oath, with respect to the foregoing application:
____________________________________________________
Signature of Ofcer and Title
____________________________________________________
Member in Charge
____________________________________________________
Member in Charge
____________________________________________________
Member in Charge
____________________________________________________
Member in Charge
If more space is needed in any section of this application, insert extra sheets of paper.
Applicant’s registration slip from the Legalized Games of Chance Control Commission
must be presented to the Municipal Clerk with this application.
Sworn and subscribed to before me this
______day of ________________ , 20 ___.
____________________________________
Notary Public (Print name)
____________________________________
Signature of Notary Public
Affix seAl here
1. The applicant (is) (is not) limited in its activities to the
furtherance of one or more authorized purposes as dened
in the Rafes Licensing Law.
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.
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 application.
5. For each occasion for which a license is sought, one or more of
the members listed who are familiar with the Rafes Licensing
Law and the Rules and Regulations, will be in full charge of,
and primarily responsible for, the conduct of the games.
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 xed by the Schedule
of Fees, as well as the compensation for the Licensed
Compensated Workers pursuant to N.J.A.C. 13:47-6A. No
prize may be offered and given in cash, except as otherwise
provided by the Rafes Licensing Law (N.J.S.A. 5:8-50 et seq.).
If a cash prize under certain circumstances is permitted by the
law, the amount of the cash prize may not exceed the limits
prescribed by the Rafes Licensing Law.
7. All statements in the foregoing application are true.
} ss.
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