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CITY OF R4SEVILLE <br /> GAMBLING LICENSE APPLICATION <br /> (FOR ORGANIZATIONS APPLYING FOR EXEMPTION FROM STATE LICENSING) <br /> ORGANIZAIM INFOMATIO <br /> Name <br /> Telephone Number <br /> Address <br /> y�_s G� . c/• or <br /> Organization's Purpose /v , <br /> GAKBLLTjQ EYENT INFQRMATION <br /> New Or Have Previously Applied <br /> Location of Event in Roseville v� <br /> Date of Gambling Activity _ �►�` �� 1�� <br /> Estimated Time of Activity <br /> 4 <br /> Dollar Amount of Total Prizes to be Awarded ��� <br /> Funds Will be Used for e <br /> APPLICANT INFORMATION <br /> Name � <br /> /<n6 <br /> Telephone Number �3 � � f in ffQ - <br /> 00 J� <br /> Signature <br /> Date � 2-1 <br /> LICENSE FEE $ 25.00 <br /> WITHIN TEN (14) 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. C bm�,,,p,,,n,W,,,o9p,,,,,,pd <br /> :3 ca 1/3 <br />