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CITY OF ROSEVILLE <br /> GAMBLING LICENSE APPLIC.aTION <br /> (FOR ORGANIZATIONS APPLYING FOR EXEMPTIOS F RO 1 S TA T L I C E N S I N 0) <br /> ORGANIZATION INFORMATION <br /> TA <br /> Name f <br /> Telephone Number <br /> Address <br /> 1IL4q L)n tW Ro a o �j n y 11 <br /> � y �-�Or anization s Purpose �u. t <br /> GAMBLING EVENT I <br /> Ne" Or Have pre`;ousk- Applied 'K <br /> Location of Event in Roseville r nn -�2 coo <br /> Date of Gambling Activit} rC)a, 4 I <br /> Estimated Time of Actil.,itti m <br /> r <br /> Dollar Amount of Total Prizes to be A w and e d _ �.. .. . <br /> Funds Wi11 be Used for _S S <br /> Of c, <br /> APPLICANT INFORMATION <br /> c r <br /> Name K, U <br /> t � l <br /> Telephone Number L L <br /> L*--tA Ci�Signature . <br /> Date 11 13 00 0 <br /> LICENSE FEE 25.00 <br /> WITHIN TEN (10) DAYS OF FILING ANY REPORTS WITH THE CHARITABLE <br /> GAMBLING CONTROL BOARD, THE ORGANIZATION SHALL FILE A COPY OF SUCH <br /> REPORTS WITH THE CITY OF ROSEVILLE. AS REQUIRED BY SECTION 125.060 OF <br /> THE CITY CODE. <br /> c 01Tite«f yin exmptvam up4 <br />