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GAMBLING LICENSE APPLICATION <br />(FOR ORGANIZATIONS APPLYING FOR EXEMPTION FROM STATE LICENSING) <br />Name Roseville- Central Park Foundation <br />Telephone Dumber 651-490-9411 <br />Address __1910 County Road B West / Roseville, MN 551.1 � <br />Organization's Purpose assist in the development of Roseville Central part <br />GAMBLING EVENT INFORMATION <br />New Or Have Previously Applied <br />Location of Event in Roseville Roseville Skating Center 01 imp i e banSlue t_ room <br />Date of Gambling Activity October 3, 2005 <br />Estimated Time of Activity 6: C'0 - 9: 00 Pm -. -- - - - -- - -- - - -- <br />Dollar Amount of Total Friers to be Awarded Not to exceed 1, 000 <br />Funds Will be Used for Roseville Cenral ark im rovements <br />APPLICANT INFORMATION <br />Name Monte S. Johnsen President <br />Telephone Number 651-490-9411 <br />Sig -nature <br />Date September 4, 2003 e <br />LICENSE FEE $ 25.00 <br />WITHIN TEN (10) DAYS OF FILING ANY REPORTS WITH THE HAMTABLE <br />GAMBLING CONTROL BOARD, THE ORGANIZATION SHALIL F I LfE A COPY OF SOCH <br />REPORTS WITH THE CITY OF RO EVILLE, AS 1 E IA ED BY SECTION 125.060 OF <br />THE CITY CODE. <br />C:%office1wpwin1.gxmpiSiLm.wpd <br />