Ill. Admin. Code tit. 26, § 210.APPENDIX A
| 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: | ||||||||||
| * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * |
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)