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CITY OF ROSEVILLE <br /> GAMBLING LICENSE APPLICATION <br /> (FOR ORGANIZATIONS APPLYING FOR EXEMPTION FROM STATE LICENSING) <br /> ORGANIZATION INFORMATION <br /> Name ��'�l/�1G� vokbvr F�1� F.zi� <br /> Telephone Number q410 <br /> Address 01 1V• L-�X.Z✓1/�%D-�!/ AVE. f Of 57141,VZ/� /`1� . ,5�(3 <br /> ' ' �Uf'f3�Y�l�cavT./� /tloti' y f O .qOrganization's Purpose A /D <br /> GAMBLING EVENT INFORMATION 'v5 15P <br /> New Or Have Previously Applied <br /> Location of Event in Roseville 9i7 d( IV- ��-�T�1/G T4/� f��/'F• F�/P� 5T+llOy <br /> Date of Gambling Activity <br /> Estimated Time of Activity <br /> Dollar Amount of Total Prizes to be Awarded_. `�7ao <br /> Funds Will be Used for FD61e4T-�� T <br /> APPLICANT INFORMATION <br /> Name - FE-APE DEpT,' <br /> Telephone Number <br /> Signature <br /> Date 13 q"�� <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\ofTice wpwin tzmptgam Npd <br />