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CITY OF ROSEVILLE <br /> AMBLING LICENSE APPLICATION <br /> (FOR ORGANIZATIONS N APPLYING FOR EXEMPTION F Oi%,l STATE LICE SIB <br /> ORGANIZATION INFORMATION <br /> 0.s f ut e.c. )0 //a 7),E U <br /> Name —L <br /> Telephone Number - <br /> Address .2 �0/ A) <br /> Organization's Purpose <br /> GAMBLING EVENT INFORMATIO <br /> New Or Have Prev iouslN- Applied <br /> Location of Event in Roseville a i � <br /> in Activity <br /> Date of Gambling <br /> Estimated Time of Activity r <br /> Dollar Amount of Total Prizes to be Awarded <br /> Funds Will he Used for c-FcJR)"A ZL <br /> APPLICANT INFORMATION <br /> Name AF CHAfL6 zv.. -):11'ex <br /> Telephone Number / � <br /> Signature <br /> Date <br /> LICENSE FEE 25.00 <br /> WITHIN TEN (10) IAA <br /> F FILING ANY REPORTS WITH THE CHARITABLE <br /> GAMBLING CONTROL BSA <br /> THE ORGANIZATION SHALL FILE A COPY OF SUCH <br /> REPORTS WITH THE CITY OF RO EVILLE. AS REQUIRED BY SECTION 125.060 OF <br /> THECITY CODE. C- office upAin c-kmptuani wru <br />