Form Wv/raf-1 - Application For Annual, Limited Or State Fair Raffle License Page 2
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3WV/RAF-1
APPLICATION FOR ANNUAL, LIMITED OR STATE FAIR RAFFLE LICENSE
rtL178 v 13-web
SECTION 3 - LOCATION OF RAFFLE OCCASIONS
Address, City, Zip Code & County
Do you own the premises?
YES
NO
Do you rent or lease the premises?
YES
NO
List name of owner:
PLEASE NOTE: YOU MUST ATTACH A COPY OF CURRENT RENTAL OR LEASE AGREEMENT WITH THE APPLICATION.
SECTION 4 - NAMES OF OFFICERS OF ORGANIZATION
LIST NAMES, HOME ADDRESSES AND HOME TELEPHONE NUMBERS OF ALL OFFICERS AND MEMBERS OF THE BOARD
DIRECTORS, GOVERNORS OR TRUSTEES, IF ANY, IN THE ORGANIZATION. ALL OFFICERS MUST BE OVER 18. (ATTACH
ADDITIONAL SHEET IF NECESSARY)
NAME AND TITLE
HOME ADDRESS
HOME TELEPHONE NUMBER
1.
2.
3.
4.
SECTION 5 - PERSONS IN CHARGE OF RAFFLE
LIST NAMES, HOME ADDRESSES AND TELEPHONE NUMBERS OF PERSONS IN CHARGE OF RAFFLE OCCASIONS. THESE
PERSONS MUST BE BONA FIDE MEMBERS OF YOUR ORGANIZATION AND RESIDENTS OF THE STATE OF WEST VIRGINIA.
ANNUAL LICENSES REQUIRE 3 NAMES. LIMITED LICENSES REQUIRE AT LEAST 2 NAMES. ONE OF THESE PERSONS
MUST BE PRESENT AT ALL RAFFLE OCCASIONS. ALL PERSONS IN CHARGE OF RAFFLE MUST BE OVER 18.
NAME AND TITLE
HOME ADDRESS
HOME TELEPHONE NUMBER
1.
2.
3.
SECTION 6 - NAME OF HIGHEST ELECTED OFFICER AND APPOINTED DESIGNEE
LIST NAMES, HOME ADDRESSES AND HOME TELEPHONE NUMBERS OF THE HIGHEST ELECTED OFFICER AND HIS OR HER
APPOINTED DESIGNEE OF THE ORGANIZATION. ONE OF THESE PERSONS MUST BE PRESENT AT ALL OCCASIONS.
ALL PERSONS MUST BE OVER 18.
NAME AND TITLE
HOME ADDRESS
HOME TELEPHONE NUMBER
HIGHEST ELECTED OFFICER
1.
APPOINTED DESIGNEE
2.
SECTION 7 - YOU MUST ANSWER THE FOLLOWING QUESTIONS
Has your raffle license application ever been refused, denied, revoked, or suspended?
YES
NO
(Circle One)
Has any person in your organization who will participate in any manner in the conduct of Raffle games or related concessions been
convicted of a felony or misdemeanor for a gambling offense within the past 10 years?
YES
NO
(Circle One)
If you answered yes to any of these questions, attach a separate sheet explaining.
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