GC-5 I
GC-5 LICENSE TO CONDUCT
NYS RACING&WAGERING BOARD GAMES OF CHANCE
1 Broadway Center,Suite 600 PLEASE CHECKi
Schenectady,NY 12305-2553
y GAMES OF CHANCE ❑
Telephone(518)395-5400 Fax(518)347-1469
www.racing.state.ny.us BELL JAR ❑
RAFFLE ❑ This License Must Be
Conspicuously Displayed
GC - During Conduct of Games
N.Y.S.Identification Number
Municipal License Number Amount of Fee Paid Lessor's License Number
The following organization:
Address: City: Zip Code:
Entire net proceeds to be devoted to the following specific lawful purpose(s):
Names of Members in Charge
LICENSE PERIOD
DATE DAY OF WEEK HOURS TYPE(S)OF GAMES
RAFFLE DRAWING (Cash or Merchandise Prizes
DATE DRAWING TIME DRAWING LOCATION AMOUNT OF RAFFLE PRIZES at Fair Market Value)
THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
FOR EACH TYPE OF GAME OF CHANCE FOR EACH MERCHANDISE WHEEL
NUMBER OF GAMES EACH GAME(Starting Bank) NUMBER OF WHEELS EACH WHEEL
THE TOTAL AMOUNT OF PRIZES FOR EACH BELL JAR GAMES SHALL BE PLAYED IN ACCORDANCE WITH
DEAL SHALL NOT EXCEED$3,000 AND NO SINGLE PRIZE STATE LAWS AND RULES AND LOCAL ORDINANCES OR
SHALL EXCEED$500. LAWS.
Issued by
(Name of Municipality) (Title of Authorized Officer)
(Date) (Signature of Authorized Officer)
L BJ-GC-5(Rev.3/06) 111111111111111111111111111111111 —1