GCRCF
r.
GC-RCF
NYS RACING & WAGERING BOARD
1 Watervliet Ave. Ext., Suite 2
Albany, NY 12206-1668
Telephone (518) 453-8460 Fax (518) 453-8492
www.racing.state.ny.us
-,.
RAFFLE
CONSENT FORM
Instructions: To be completed by Authorized Organizations that intend to sell raffle tickets outside the licensing
municipality. Submit completed form to licensing clerk in municipalities where organization wants
to sell raffle tickets. (Per 9E NYCRR Section 5620.22(6) )
of
I,
(Print the flfst name. middle initial and last name of the officer or director) (Title of officer or director: Pastor, Commander. etc.)
,GC [0- [IJ] -[il]-DIIII
,
(Name of authorized organization)
(Games of Chance Identification Number)
located at
. (Street Address)
(City)
(Zip)
request permission from the
(City. Town or ViJlage)
County of
, to sell raffie tickets licensed by the
, County of
, within
(City, Town or Village)
the territorial limits of its municipality during the calendar year
(Signature of authorized organization's officer or director)
Sworn to me this
day of
, 20
(Commissioner of Deeds)
(Notary Public)
Approved by:
(Name of Municipality)
(Signature of Authorized Officer)
(Title of Authorized Officer)
I
I
. (Date)
Note: Municipalities which have enacted legislation authorizing the conduct of games of chance may consent to
allow the sale of raffle tickets by authorized organizations licensed to conduct raffles by another municipality
only if the licensing municipality is located in the same county as the consenting m,unicipality, or in a county
that is contiguous to the county in which the consenting municipality is located, in accordance with Section 189.
Subdivision 13 of the General Municipallaw.
L Fonn BJ-GC-RCF (Rev. 4/03) 11111111111111111111111111111 ~