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2. Online Raffle Sales Application
3. Ordinance 09-O-18
5. Applicant First Name*
6. Applicant Last Name*
8. Name of Organization
9. Organization Type
   -- Select One --ReligiousCharitableLaborFraternalEducationalVeteran'sNon-Profit
11. Physical Address*
13. City*
14. State*
15. Zip*
17. Mailing Address if Different than Above
19. City
20. State
21. Zip
23. Raffle Manager First Name*
24. Raffle Manager Last Name*
26. Raffle Manager Address*
27. Raffle Manager Phone Number*
29. Raffle Manager E-Mail*
31. City*
32. State*
33. Zip*
35. Raffle Purpose*
37. Number of Raffles*
    If the license is to authorize more than one raffle, specify the number of raffles to be conducted within one year of date of this application. If license is to cover more than one raffle, submit a raffle information form for each additional raffle.
39. Yes or No*

    Non-Profit fund raising for the sole purpose of providing financial assistance to an identified individual or group of individuals suffering extreme financial hardship as a result of an illness, disability, accident or disaster.

    1. Yes
    2. No
41. Place or Area where tickets will be sold?*
43. Maximum amount charged for each ticket for the raffle?*
    not to exceed $200.00.
45. Aggregate retail value of all prizes to be awarded at the raffle?*

    not to exceed $200,000.

    Ex: (Prize #1 retail value + Prize #2 retail value + Prize #3 retail value = Aggregate TOTAL)

47. Maximum retail value of prize to be awarded at the raffle?*

    not to exceed $100,000.

    List the prize with the largest retail value 

49. What will be the time span for which tickets will be sold?*
    not to exceed 180 days.
51. Location of Drawing to Determine Winner*
    (Must be within Waukegan city limits)
52. Date and Time of the Drawing*
    Date and Time of the Drawing

    Date and Time of the Drawing
54. Does the applicant own premises where the drawing is to be held?*

    1. Yes
    2. No
56. What is the lease holders name?*
58. Does the lease holder have a raffle permit?*

    NOTE: Pursuant to the Illinois Raffles Act, a licensee may rent a location at which to conduct the raffle drawing only from an organization who is also licensed.

    1. Yes
    2. No
60. Do you have a fidelity Bond?*

    1. Yes
    2. No
61. Fidelity Bond*
    Please attach a copy of the manager's fidelity bond.
63. Fidelity Bond Waiver Request*

    1. Waiver Request

    By unanimous vote of members of the organization, the applicant requests a waiver of manager's fidelity bond.
65. Acknowledgement
    The undersigned, being duly sworn, on oath depose and state as follows: That the above named organization is organized not-for-profit under the law of the State of Illinois and has been continuously in existence for 5 years preceding the date of this application, and that during the entire 5 year period preceding the date of this application it has maintained a bona fide membership actively engaged in carrying out its objectives, or to a non-profit fund raising organization organized for the sole purpose of providing financial assistance to an identified individual or group of individuals suffering extreme financial hardship as the result of an illness, disability, accident or disaster. The undersigned state that all statement in the foregoing application are true and correct; that the officers and operators are all of good moral character and have not been convicted of a felony nor have been a professional gambler or promoter of a gambling operation; that if a license is granted hereunder, the undersigned will be responsible for the conduct of the drawing in accordance with the provisions of the Illinois Raffles Act and the City of Waukegan Ordinance Establishing a System for the Licensing of Raffles.
67. Applicant Signature
    I, hereby, acknowledge that the information provided is true and correct and I am authorized to sign on the organizations behalf.
Leave This Blank:


69. 1. Receive an email copy of this form.
70. Email address

    This field is not part of the form submission.

71. Submit

* indicates a required field