Application For Annual, Limited Or State Fair Raffle License (Page 3 of 3) in pdf

Application For Annual, Limited Or State Fair Raffle License Page 3

WV/RAF-1

APPLICATION FOR ANNUAL, LIMITED OR STATE FAIR RAFFLE LICENSE

rtL178 v.8-web

SECTION 8 - NAME OF RAFFLE DISTRIBUTOR

You must list the name, address and phone number of the distributor(s) where you purchase your raffle supplies.

NAME OF DISTRIBUTOR

ADDRESS

TELEPHONE NUMBER

SECTION 9 - DISPOSITION OF PROCEEDS

Recipient of Proceeds:

Does this recipient have an Internal Revenue Service Exemption Letter?

YES

(Circle One)

Intended use of Proceeds:

PLEASE NOTE: YOU MUST LIST THE NAMES OF ALL ORGANIZATIONS YOU INTEND TO DONATE PROCEEDS TO.

ATTACH SEPARATE SHEET IF NECESSARY.

SECTION 10 - PROOF OF EXISTENCE (NOT REQUIRED FOR RENEWAL APPLICANTS)

HAS YOUR ORGANIZATION BEEN IN EXISTENCE IN WEST VIRGINIA TWO YEARS PRIOR TO FILING THIS APPLICATION:

YES

(Circle One)

IF YES, YOU MUST ATTACH DOCUMENTARY PROOF. THIS DOCUMENT IS NECESSARY TO QUALIFY FOR A RAFFLE

LICENSE.

SECTION 11 - CONCESSIONS

WILL A CONCESSION BE OPERATED?

YES

(Circle One)

WILL THE LICENSEE OPERATE THE CONCESSION?

YES

(Circle One)

PLEASE NOTE: IF THE CONCESSIONS ARE TO BE OPERATED BY SOMEONE OTHER THAN THE LICENSEE, A COPY OF

ANY AGREEMENT OR AN EXPLANATION OF ANY ORAL AGREEMENT PROVIDING ANY COMPENSATION TO THE

OPERATOR OF THE CONCESSION MUST BE ATTACHED.

SECTION 12 - AGREEMENT

I fully understand that it is a violation of Chapter 47, Article 21 to allow anyone other than authorized persons to conduct any part of the Raffle Games or concessions; That I am

required to file reports and keep records as provided by Article 21; That it is a crime to violate any provisions of Article 20; That a violation may result in suspension and/or

revocation of the license and possible denial of future license applications.

, AS AN AUTHORIZED REPRESENTATIVE OF

CERTIFY OR AFFIRM THAT THE STATEMENTS AND ITEMS ENTERED HEREIN AND ATTACHED HERETO ARE TRUE AND CORRECT TO THE BEST OF MY

KNOWLEDGE.

(Name - Type or Print)

(Signature)

(Date)

(Telephone Number)

(Email Address)

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