Application for a Raffles License Application No: RA

Name of municipality: Bernards Township

Identification No:   (REQUIRED)

Part A - General

Kind of Game:

VALUE / FEE:    

1. Name of applying organization:    (REQUIRED)
2 a. Street address of headquarters: (REQUIRED)
Address:
City: State: ZIP:
   b. Mailing address (if different):

3. A license is requested to conduct raffles of the kind stated on the date, or on each of the dates, and during the hours listed (use a separate application for each type of raffle).
Date (i.e., 05/01/2013) Hours (i.e., 8:00AM to 4:00PM) Date Hours
4a. Address of place where raffles will be played: (REQUIRED)
Address:
City: State: ZIP:
  b. Does the applicant own the premises or regularly occupy them for its general purposes?    (REQUIRED Yes Or No)

5. If raffles equipment is to be rented, attach a statement by the raffles equipment lessor to this application on Form 13.
Part B - Schedule of Expenses
The items of expense intended to be incurred or paid in connection with the games listed in this application, the names and addresses of the persons to whom each item is to be paid, and the purpose for which each item is to be paid, are:
Item of Expense Name and address of supplier Purpose
Part C - Schedule of Purposes
1. The specific purpose(s) to which the entire net proceeds of the games listed in this application are to be devoted, and the manner in which they are to be so devoted, are: (REQUIRED)
2. If any part of the net proceeds are to be devoted to a purpose allowed by the Raffles Licensing Law by turning the same over to another organization which is exclusively devoted to such purposes, secure the signature of its president or other executive officer to the following certificate:
"It is hereby certified that will accept from the licensee any part of the net proceeds of the games listed in this application to be turned over to it."

Date: ____________________

Signature: ________________________________________

Part D - Schedule of Prizes

A description of all prizes to be offered and given in all of the games listed in this application is as follows. For merchandise, describe the article and state the retail value; if prizes are to be donated, indicate that fact and estimate as accurately as possible the information requested below.

Description of Prize Donated (Yes or No) Retail value (example $10.00 or $150.00)

         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
Part E - Officers of Applicant
At least one officer must be listed with all fields completed.
(1) Office (REQUIRED)
Name of officer
(REQUIRED)
Age
(REQUIRED)
Residence address (REQUIRED)
Telephone No. (include area code 123-456-7890) (REQUIRED)
Day  
Evening  
(2) Office
Name of officer Age
Residence address
Telephone No. (include area code 123-456-7890)
Day  
Evening  
(3) Office
Name of officer Age
Residence address
Telephone No. (include area code 123-456-7890)
Day  
Evening  
(4) Office
Name of officer Age
Residence address
Telephone No. (include area code 123-456-7890)
Day  
Evening  
Part F - Members of Applicant who will be in charge of the games
At least one member in charge must be listed with all fields completed.
Name of member in charge (REQUIRED) Residence addresses (REQUIRED) Telephone No.
(include area code
123-456-7890)
Day / Evening
(REQUIRED)
Age (REQUIRED)
    /  
/    
/    
/    
/    
Part G - Members of Applicant who will assist in conducting the games
Name of member Residence addresse Age
Part H - Names of other organizations whose members will assist in conducting the games
Name and address of organization How related Identification No.
If more space is needed in any section of this application, insert extra sheets of paper.
Part I - Statement of Applicant and member(s) in charge
State of New Jersey
County of Somerset
} ss.


We do hereby each make the following statement, under oath, with respect to the foregoing application:

1. The applicant (is) (is not) limited in its activities to the furtherance of one or more authorized purposes as defined in the Raffles Licensing Law.

2. Prior to the issuance of any license to it to conduct games of chance, the applicant was actively engaged in serving one or more “authorized purposes.”

3. The applicant has received and used, and in good faith expects to continue to receive and use, to further one or more authorized purposes, funds from sources other than games of chance.

4. The conduct of the games on the occasion or occasions for which this application is made will be to raise and devote the entire net proceeds to the authorized purpose described in the application.

5. For each occasion for which a license is sought, one or more of the members listed who are familiar with the Raffles Licensing Law and the Rules and Regulations, will be in full charge of, and primarily responsible for, the conduct of the games.

6. No commission, salary, compensation, reward or recompense will be paid to any person for holding, operating or conducting or assisting in the holding, operation or conducting, of the games, except to bookkeepers or accountants for professional services not exceeding the amounts fixed by the Schedule of Fees, as well as the compensation for the Licensed Compensated Workers pursuant to N.J.A.C. 13:47-6A. No prize may be offered and given in cash, except as otherwise provided by the Raffles Licensing Law (N.J.S.A. 5:8-50 et seq.). If a cash prize under certain circumstances is permitted by the law, the amount of the cash prize may not exceed the limits prescribed by the Raffles Licensing Law.

7. All statements in the foregoing application are true.

Sworn and subscribed to before me this
______day of_________________, 20_ ___.
____________________________________
Notary Public (Print name)
____________________________________
Signature of Notary Public

____________________________________________________
Signature of Officer and Title
____________________________________________________
Signature of Member-in-Charge
____________________________________________________
Signature of Member-in-Charge
____________________________________________________
Signature of Member-in-Charge
____________________________________________________
Signature of Member-in-Charge
If more space is needed in any section of this application, insert extra sheets of paper.
Applicant's registration slip from the Legalized Games of Chance Control Commission
must be presented to the Municipal Clerk with this application.


Email Address: (REQUIRED):

Please check that all fields are complete.
Instructions for printing will follow after you submit the application.