___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
_______
Please attach photo IDs for all listed on application.
Presiding Officer:
Name
_____________________________________________________________________________
Phone#
_______________________________
First MI Last
Address
__________________________________________________________________________________________________________________
Street City State Zip Code
Last 4 of Social Security # XXX-XX-_______ IL Driver’s License #____________________________
Date of Birth_______/______/_______ Place of Birth________________________________________
Raffles Manager:
Name
___________________________________________________________________________
Phone#
________________________________
First MI Last
Address
__________________________________________________________________________________________________________________
Street City State Zip Code
Last 4 of Social Security # XXX-XX-_______ IL Driver’s License #____________________________
Date of Birth_______/______/_______ Place of Birth________________________________________
List names of members who will be responsible for conduct and operation of raffles (use additional page
if needed): Number of members responsible:_________ ATTACH PHOTO IDs FOR EACH LISTED
NAME (First, MI, Last) DATE OF BIRTH PHONE#
NAME (First, MI, Last) DATE OF BIRTH PHONE#
NAME (First, MI, Last) DATE OF BIRTH PHONE#
THE UNDERSIGNED ATTEST THAT:
(Please initial after each)
1. The above-named organization is organized not-for-profit under the law of the State of Illinois and
has been in continuous existence for 5 years, preceding date of this application, and that during
this entire 5-year period preceding date of application, it has maintained a bona fide membership
actively engaged in carrying out its objects. ______
2. Applicant has received a copy of City Code Chapter 62 and agrees to abide by its provisions.
3. That the above-named organization, officers, operators and workers of the games are not ineligible
for the license according to Section 6 of Chapter 62 and that said officers, operators and workers
of the games are bona fide members of the sponsoring organization. _______
4. That if a license is granted hereunder, the undersigned will be responsible for the conduct of the
games in accordance with the provisions of the laws of the State of Illinois and this jurisdiction
governing the conduct of such games (Section 7 of Chapter 62). _______
5. Does hereby state under penalties of perjury that all statements in the foregoing application are
true and correct. _______
Presiding Officer’s Signature ______________________________________________
Secretary’s Signature__________________________________________________
Name of Organization_______________________________________________
Today’s Date_____________________________________________________________
5-3-80A
