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Application to Operate a Non-profit raffle

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1. Waiver of Liability to operate non-profit raffle/drawing/fund-raiser This section is complete This section is incomplete
2. Page 1 This section is complete This section is incomplete

Waiver of Liability to operate non-profit raffle/drawing/fund-raiser

I, (fill in name below) understand that the Lumpkin County Sheriff's Office will not be held responsible for any accident, injury or death of any participant involved with this fund raising event.*
**The Lumpkin County Sheriff's Office encourages all participants to use caution and to have due regard for the safety of the participants and others during this event.
***The Lumpkin County Sheriff's Office encourages you to make every effort not to impede the flow of traffic.
1. Name of Charity/Event
2. Date of Charity/Event
3. Type of Charity/Event
4. Location of Charity/Event
Continue

Page 1

List name, address and phone number of each person who will operate, advertise or promote drawing/raffle.
Name:
Address:
Phone Number
Name:
Address:
Phone Number:
Name:
Address:
Phone Number:
Name:
Address:
Phone Number:
Electronic Signature Agreement
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Electronic Signature
Date/Time*
Date/Time
Date/Time
Witness
Date/Time
Date/Time
Date/Time
First Name
Last Name
Notary
First Name
Last Name
My Commission Expires
Date
Lumpkin County Sheriff's Office Application for License to Operate Non-profit raffle/drawing/fund-raiser
Fill out completely and return to Lumpkin County Sheriff's Office. Please allow 2 weeks for processing.
Name of Charity/Event
Date of Charity/Event
Type of Charity/Event
Location of Event
Items for Raffle/Drawing
Cost Per Ticket
Name of Applicant
Date of Birth
Street Address
City, State Zip
Home Phone Number
Cell Phone Number
Email Address
If Corporation, Association or other legal entity, please include a request on your stationary or letterhead with signature of ceo/supervisor.
List name, address and phone number of each person who will operate, advertise or promote drawing/raffle
Name
Street Address
City, State, Zip
Phone Number
Name
Street Address
City, State, Zip Code
Phone Number
Name
Street Address
City, State, Zip Code
Phone Number
Name
Street Address
City, State, Zip Code
Phone Number
I certify that all the above information is true and correct to the best of my knowledge
Electronic Signature Agreement
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Electronic Signature
Date/Time
Date/Time
Date/Time
I approve this Non-Profit raffle/drawing/fund-raiser event.
Sheriff Stacy M. Jarrard, Lumpkin County Sheriff's Office
Date

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Lumpkin County Sheriff's Office Open Records Request

Contact Us

99 Courthouse Hill
Dahlonega, GA 30533

Phone: 706-864-3742
Fax: 706-482-2697

E-Verify Number: 126741
Authorization Date: 06/12/2008

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