Raffle
.
I
GC-RCF
NYS RACING & WAGERING BOARD
I Broadway Center, Suite 600
Schenectady, NY 12305-2553
Telephone (518) 395-5400 Fax (518) 347-1469
www.racing.state.ny.us
I
RAFFLE
CONSENT FORM
Instructions: This form must be completed by each Authorized Organization that intends to sell raffle tickets in
a municipality other than the city, town or village in which it is domiciled and in which it is either
issued a raffle license or is authorized to conduct raffles pursuant to Article 9-A, General
Municipal Law, Section 190-a. *
I, :::DE-AtJ:D. ~A^,A L- t.. ,
(Print the first name, middle initial and last name of the officer or director)
T~EAs v 4..E/<..
(Title of officer or director: Pastor, Commander, etc.)
of
F/5f-IKI'-'-' EL€/VJBVTAl<y SCI/OOL prA
(Name of authorized organization)
,GC ,
(Games Of Chance Identification Number, if required)
located at 20 (3 ffv.t< crt s r. FISH J< 1'- L-, Iv' Y 1252 ~ - 130i
(Address of authorized organization)
request permission from the
TO~'l/N OF WfI i?/lhVtiiER
(City, Town or Village)
County of 'DJ 'Ie 1-16 s.s
V /L'-A6;E of FI5I1klt..-t..-
(City, Town or Village)
, to sell raffle tickets licensed by the
, County of .:pc/rCHE 5 s
, within
the Mthin the .terr1
~ I.
. I limits of its municipality during the calendar year 2009
PRISCilLA M BAUCKI
NO 01BA6112720 Y k
ill" State of New or
NO~~Ya~~d 'fn Orange CO~U~~ 2D l2-
My Commission Expires -~.' ~
Sworn to me this JJg!!}day of ~, zooq
(Y ear)
o G
Approved by: Wft PP I 10GE: ~
(Name of Municipality)
(Notary Public - Commissioner of Deeds)
; (Signature and Title of Authorized Officer)
, ~oq(Date)
* Note: A municipality that has enacted legislation authorizing the conduct of games of chance may consent to
permit the sale of raffle tickets within its territorial limits by an authorized organization that is either licensed
to conduct raffles or is authorized by Section 190-a of the General Municipal Law to conduct raffles in the
municipality in which it is domiciled, only if the authorized organization's municipality is located in the same
county as the consenting municipality, or is located in a county that is contiguous to the county in which the
consenting municipality is located, pursuant to Article 9-A, General Municipal Law, Section 189, Subdivision
13.
L Form BJ-GC-RCF (Rev. 09/07)
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