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CITY OF ROSEVILLE <br /> GAMBLING LICENSE APPLICATION <br /> (FOR ORGANIZATIONS ATION APPLYING FOR EXEMPTION PTIOBI FRO STATE LICENSING) <br /> ORGANIZATION INFOMATION <br /> N 9 ". t,4"" <br /> ame- ru�� '14y <br /> Telephone Number <br /> Address - <br /> x <br /> ifs _L.�� }'' ' �` c:��� ` *� � �f' .`� <br /> Organization#s Purpose I 1r)ri, <br /> GAMBLING EVENT INFORMATION <br /> New Or Have Pre%-�ously AFPl*ed <br /> Location of Event in Roseville CT ■ <br /> Ci <br /> Date of Gambling Activity <br /> Estimated Time of Activity <br /> Dollar Arnount of Tats Pnzes to be Awarded <br /> Funds Will be Used for <br /> 6 <br /> AXpLICANT INFORMATION <br /> Name . <br /> Telephone hone Number <br /> J/ <br /> Signature <br /> UFF <br /> Date # <br /> LICENSE FEE .00 <br /> WITHIN TEN (10) DAYS <br /> OF FILING ANY REPORT'S WITH TFIB CHARITABLE <br /> GAMBLING CONTROL BOARD, THE ORGANIZATION SHALL FILE A COPY OF SUCH <br /> REPOF.TS WITH THE SIT <br /> OF ROSEVILLE, AS REQUIRED BY SECTION 125.060 OF <br /> THECITY CODE. c office wF%--in,exmPtyam wra <br />