§210.APPENDIX A. Application Form

FORM DR			LICENSE APPLICATION TO CONDUCT A RAFFLE
1.	Name and address of political committee.
2.	Type of Committee  (Circle One)
	Candidate				Political Party	Political Action Committee		Ballot Initiative
3.	Name and address of officers.
	A.		Chairman
							Phone Number:
	B.		Treasurer
							Phone Number:
4.	Name and address of individuals responsible for the conduct of the raffle.
5.	Locations where raffle chances will be sold or issued.
6.	First and last dates for sale of raffle chances.
7.	Locations where winning chances will be determined.
8.	Dates of determination of winning chances.
	Briefly describe the prizes:

 

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The undersigned hereby swear and affirm that __________________________________ is organized as a political committee in Illinois as required by Article 9 of the Election Code and is eligible to receive a raffle license as prescribed by law, and further, that the above stated facts are true. We acknowledge the receipt of copies of 230 ILCS 15/8.1 and of 26 Ill. Adm. Code 210.10 and understand that failure to abide by the Election Code shall void any license granted to this committee.

					For Office Use Only
Chairman (Signature)					Identification No.
					Date of Creation:
Treasurer (Signature)
Subscribed and Sworn to before me this					Approved
___ day of ____________, 20____.							(Date)
Notary Public				(Signature)

 

(Source:  Amended at 35 Ill. Reg. 2407, effective February 4, 2011)