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Jul 25 02 08: 10a EARNERS INS 6122432779 P• 1 <br /> CITY OF ROSEVILLE <br /> GAMBLING LICENSE APPLICATION <br /> (FOR ORGA1vIZATIONS APPLYING FOR EXEMPTION FROM STATE LICENSING) <br /> ORGANIZA—TION INFORMATION. <br /> Name_� �i1uL.�. <br /> 'Pt-Sr;- 1��i?r_ <br /> Telephone Number �j) <br /> Address J27 Ot -P• 4EXIA16-M�J VC <br /> Organization's Purpose as=x*ttA 1=t.-F' <br /> CxAM3T,TNCx EVENT T <br /> New Or Have Previously Applied � <br /> Location of Event in Roseville_cO7al A/P <br /> Date of Gambling Activity <br /> Estimated Time of Activity :UQ0.2M <br /> Dollar Amount of Total Prizes to be Awarded � [i,�'S"b 00-6 <br /> Funds Will be Used for a y1f <br /> APPLICANT INFORM&UM <br /> Nacre �i,�AV <br /> Telephone Number 1�1%-1 - <br /> Signature <br /> Date <br /> LICENSE FEE $25.00 <br /> WITHIN TEN (lo) DAYS OF FILING ANY REPORTS WITH THE CHARITABLE <br /> GAMBLMG 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•'IolBee%wpwk+kwnp16am.wpd <br />