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X Yes 0 No I Have Internal Controls been submitted previously on a form provided by the Board? If no, please attach copy <br />4. Applicant (Official. legal name of organization) 5. Business Address of Organization <br />miovm+ S0S.Q;U4V1_ ASSOCAPiornon I P 0 rS w�c I R 12- g; OR <br />114. Number of active members, 15,. Number of years in existence, <br />I "r I I <br />116. Name of' Chief' Executive Officer (,Cannot be <br />Gambling Manager) <br />Title <br />Business Phone, Number <br />18. Name of' establishment where garnbling will be conducted <br />11 1 <br />Cnv, Sta�tei, ZIP <br />-IMF% <br />91, <br />CG-0001 -03 13 -*81 1 <br />Wh' ilte Cop's- Board <br />Note- Attach evidence of <br />three years existence. <br />17. Name of treasurer or person who accounts for other <br />revenues of the organization (Cannot be Gambling Manager) <br />S <br />IBM <br />Business Phone Number <br />19. Street address (not P.O. Box Number) <br />21. County (where gambling premises is located) <br />Canary-Applicant <br />Pink-Local Governing Body <br />