Section 210

Section 210.APPENDIX A Application Form

FORM DR		LICENSE APPLICATION TO CONDUCT A RAFFLE
1.	Name and address of political committee.

2.	Type of Committee (Check One) State______ Local______
	If Local, activity in which county (ies)________________________
	State ______ Local ______
	If State & Local, activity in which county (ies)

3.	Name and address of officers.
	A.	Chairman
			Phone Number:
	B.	Treasurer
			Phone Number:
4.	Name and address of individual(s) responsible for the conduct of the raffle.

				.
5.	Location(s) which raffle chances will be sold or issued.

6.	First and last dates for sale of raffle chances.

7.	(a) Location(s) at which winning chance(s) will be determined.

8.	Date(s) of determination of winning chance(s).
	Date:
	Briefly describe the prizes:

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

The undersigned hereby swear and affirm that __________________________________

is organized as a political committee in Illinois as required by Chapter 46, Article 9, Illinois Revised Statutes, An Act to Regulate Campaign Financing 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 P.A. 86-394 and of Illinois Adm. Code. Sec.210.10 and understand that failure to abide by the Act shall void any license granted to this committee.

	For Office Use Only
Chairman (Signature)	Identification No.
	Date of Creation:
Treasurer (Signature)
Subscribed and Sworn to before	Approval
me this_______________ day of		(Date)
______________, 19____.

Notary Public	(Signature)