Application For A Raffles License Form Page 2
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4Part C - Schedule of Purposes
1. The specific 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 Raffles 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 officer to the following certificate:
“It is hereby certified 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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