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CITY OF ROSEVILLE <br />GAMBLING LICENSE APPLICATION <br />(FOR ORGANIZATIONS APPLYING FOR EXEMPTION FROM STATE LICENSING) <br />M Pon <br />Name N.0csNfV1L-Lt V%-2� 00T.. AuXiLA-i2 <br />Telephone Number 1-1 130 '- �t 3 C) 0 <br />Address � 7 o t A; . L E: x) Y,6,-ro UZ, <br />EEEWW� <br />.001M <br />Organization" ization s P urpose 600VA h/P 1 e•l FfL <br />GAMBLING YET OLIFOHMAT101y <br />New Or Have Previously Applied <br />Location of Event in Roseville .9701 V. 'fX4 Px--"(� IV <br />Date of Gambling Activity 0.c7ro e3.-%P. 2vo3 <br />Estimated Time of Activity 0 U w1 <br />Dollar Amount of Total Prizes to be Awarded � h SLR• 00 <br />Funds Will be Used for Ct-0i -r *&,,F e'lwA16- <br />APPLICANT INFORMATION <br />or _ <br />rii � <br />/ v <br />r r <br />/ r � <br />/rl <br />/ <br />r /1/ <br />v � r <br />Signature <br />Date � 5 d3 <br />LICENSE FEE $ 25.00 <br />Clr4 <br />WITHIN TEN (10) DAYS OF FILING ANy REPORTS REpORTS W1 q THE CHARITABLE <br />GAMBLING CONTROL BOARD, THE ORGANIZATION SHALL FILE A COPY OF SUCH <br />REPORTS WITH TIE CITY 'OF ROSE ILLE, AS REQUIRED BY SECTION 125.060 OF <br />THE CITY CODE. <br />C:%0f[iee{wPwiQUxmp1& nm A-pd <br />