GC-5
I
GC-5
NYS RACING & WAGERING BOARD
1 Broadway Center. Suite 600
Schenectady, NY ] 2305-2553
Telephone (518) 395-5400 Fax (518) 347-1469
www.racing.state.ny.us
-,
LICENSE TO CONDUCT
GAMES OF CHANCE
PLEASE CHECK
GAMES OF CHANCE 0
BELL JAR 0
RAFFLE 0
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GC - [I] - [II]- [II] - ITIIIJ
N.Y.S. Identification Number
This License Must Be
Conspicuously Displayed
During Conduct of Games
Municipal License Number
The following organization:
$1 II
Amount of Fee Paid Lessor's License Number
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
DATE
DRAWING TIME DRAWING LOCATION
AMOUNT OF RAFFLE PRIZES (Cash or Merchandise Prizes
at FaIr Market Value)
THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
FOR EACH MERCHANDISE WHEEL
$
! THE MAXIMUM AMOUNT OF PRIZES TO BE AWARDED
FOR EACH TYPE OF GAME OF CHANCE
$
NUMBER OF GAMES
EACH GAME (StartIng Bank)
NUMBER OF WHEELS
EACH WHEEL
ITHE TOTAL AMOUNT OF PRIZES FOR EACH BELL JAR
DEAL SHALL NOT EXCEED $3,000 AND NO SINGLE PRIZE
iSHALL EXCEED $500.
GAMES SHALL BE PLAYED IN ACCORDANCE WITH
ST A TE LAWS AND RULES AND LOCAL ORDINANCES OR
LAWS.
Issued by
(Title of Authorized Officer)
(Name of Municipality)
(Signature of Authorized Officer)
11111111111111111111111111111 -.J
(Date)
L BJ-G~-5 (Rey. 3/06)