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PLC:

a0070h

Agency:

mclean county circuit clerk

For:

administration raffle licenses

Phone:

309-888-5110

Address:

115 e washington st room 401
bloomington, illinois 61701

*Required Field

Payment Information

*Name:

Middle:

*Last:

*Exact Name of Applicant Organization:

*Phone Number:

(### - ### - ####)

*Email Address:

*Type of License:

Raffle-Application-Licensing

*Price of each Raffle Ticket from the application:

*Total Retail Value of All Prizes from the application:

If you are paying the licensing fee for multiple raffle licenses please list the class, ticket price, and total retail value of all prizes for each additional raffle.

Additional Raffle (please explain):

Payment Amount

Payment Amount :

Subtotal:

$0.00

Total:

$0.00

Billing Information

*First Name:

Middle Initial:

*Last Name:

*Billing Address:

*City:

*State/Province:

*Zip:

*Country:

*Phone Number:

*Credit/Debit Card:

(enter the full card number without any dashes or spaces)

*Expiration Date:

*Card Security Number: