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2. Indicate License Requested*

   Note: Fee must accompany application.

   1. Class A: Raffle where the aggregate value of all prizes awarded does not exceed $50,000, no license fee shall be required.
   2. Class B: Raffle where the aggregate value of all prizes awarded is greater than $50,000, the license fee shall be $1,000.
6. Organization Name*
8. Address of Organization
10. Address Line 2
12. City
13. State
14. Zip
18. Raffle Manager's Name*
19. Raffle Manager's Phone Number*
21. Raffle Manager's Address*
23. Address Line 2
25. City*
26. State*
27. Zip
29. Raffle Manager's Fidelity Bond (Amount)
    Bond shall be in face amount of total amounted to be awarded to each raffle.
30. Raffle Manager's Fidelity Bond Company
32. Bond Waiver Requested*

    1. Yes
    2. No
33. If yes, please describe your reasons:
37. Total aggregate value of all winnings*
    Enter the amount.
39. List of prizes and aggregate values of each *
41. Maximum amount to be charged for raffle chances
43. Indicate the area within the village in which raffle chances are to be sold and issued. *
45. The sale of raffle tickets will commence on*
    The sale of raffle tickets will commence on

    The sale of raffle tickets will commence on
    When does the sale of raffle tickets begin?
46. The sale will continue until*
    The sale will continue until

    The sale will continue until
    When does the sale of raffle tickets end?
48. How long will the sale of raffle tickets last?
    Tell us how many days the sale of tickets will last.
50. Date and time drawings will be conducted*
    Date and time drawings will be conducted

    Date and time drawings will be conducted
51. Place where raffle winners will be selected*
53. Manner in which raffle winner will be selected*
57. Raffle Agreement
    The undersigned attest that the above named organization is eligible for a raffle license and meets all criteria pursuant to Chapter 17 of the Comprehensive Code of the Village of Bloomingdale. The undersigned do hereby state under penalties of perjury that all statements in the foregoing application are true and correct; that the officers and operators are of good moral character, have not been convicted of a felony, are in compliance with all terms and conditions of Chapter 17 of the Comprehensive Code of the Village of Bloomingdale; that if a license is granted hereunder, the undersigned will be responsible for the conduct of the raffle and drawing in accordance with all provisions of all laws of the Village of Bloomingdale and State of Illinois.
    
    I, the undersigned, have read the rules and regulations of Title 4, Chapter 4 in the Village of Bloomingdale Municipal Code and the State of Illinois Statutes relating to raffles.
    
    I, the undersigned, have never been convicted of a felony, nor have been known as a professional gambler or a promoter of a gambling operation.
59. Articles of Incorporation Requirement
    A copy of the articles of incorporation and/or charter of the organization making application must accompany this application. If already on file, please note.
61. President Signature
63. Name of Organization
65. Secretary
Leave This Blank:


66. Print Only

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