Section 210.APPENDIX A
Application Form
FORM DR
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LICENSE APPLICATION TO
CONDUCT A RAFFLE
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1.
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Name and address of political committee.
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2.
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Type of Committee (Circle One)
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Candidate
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Political Party
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Political Action Committee
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Ballot Initiative
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3.
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Name and address of officers.
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A.
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Chairman
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Phone Number:
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B.
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Treasurer
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Phone Number:
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4.
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Name and address of individuals responsible for the
conduct of the raffle.
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5.
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Locations where raffle chances will be sold or issued.
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6.
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First and last dates for sale of raffle chances.
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7.
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Locations where winning chances will be determined.
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8.
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Dates of determination of winning chances.
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Briefly describe the prizes:
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* * * * * * * * * * * * * * *
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
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The undersigned hereby swear and
affirm that __________________________________ is organized as a political
committee in Illinois as required by Article 9 of the Election Code and is
eligible to receive a raffle license as prescribed by law, and further, that
the above stated facts are true. We acknowledge the receipt of copies of 230
ILCS 15/8.1 and of 26 Ill. Adm. Code 210.10 and understand that failure to
abide by the Election Code shall void any license granted to this committee.
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For
Office Use Only
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Chairman
(Signature)
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Identification No.
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Date of Creation:
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Treasurer
(Signature)
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Subscribed and Sworn to before
me this
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Approved
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___ day of ____________,
20____.
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(Date)
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Notary Public
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(Signature)
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(Source: Amended at 35 Ill.
Reg. 2407, effective February 4, 2011)