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GAMBLING LICENSE APPLICATION <br />(FOR ORGANIZATIONS APPLYING FOR EXEMPTION FROM STATE LICENSING) <br />ORGANIZATION INFORMATION <br />Name f '1,f (LL, C- 0 (jr ` ' L, l '�^ �b b f) <br />Telephone Number <br />l -r <br />Address T� ��l�r`i�. c\� c L <br />Organization's Purpose -SO � Y^CA. r% <br />GAMBLING EVENT INFORMATION <br />New Or Have Previously Applied <br />Location of Event in Roseville i�� 0 S z L� Lk-L <br />Date of Gambling Activity 3 <br />Estimated Time of Activity (D on <br />Dollar Amount of Total Prizes to be Awarded b 0 U U <br />Funds Will be Used for 11 L `•Z% -,✓t �(. 4 P.�� E- <br />u <br />APPLICANT INFORMATION <br />Name BeA0,(ALQ- <br />TelephoneNumber <br />Signati <br />Date <br />LICENSE FEE S 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�nfretwpwinkxmp, gam wpd <br />