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Organiza6on currenvprevious license number currentlfpteveus exempt number <br />Northwest Suburban Youth Service Bureau dbl <br />0 0 ip ip <br />75 <br />Gamblil4g Site <br />Name of site where acdvity wil�l take pl�acei <br />street city State 7jpl code <br />2801, N. Snelling Ave,. Rol s evil 11 le, NN 55113 <br />Date(s) of activity <br />-November 161, 1989 <br />T�jnesl of Games <br />no,*il wvi prom oeltsea: <br />To -support tlh,e programs, o S'iub.,, <br />Youth, a--501,–ci3 organizatio-n. serving <br />ir <br />youth. <br />OeCfaffl 811 InrOrMaVei SJDMIU-..�'rx W ft�tgi jWXr-Jrfhl9?nF Or Aelien.V� <br />is irm, a=raie, end clomple to <br />Local Govemment Acknowledgement <br />I have rece,ived'a copy, of this appilica,bon. This appllication will be reviewed by the Department of Revenue andl will become, elf fine 30 days <br />from the date of relceipit by the ciry or counrt o, ess the local government passes a resolution to specificallly prohibit the activity. A copy of that <br />relsollultion m�usit be received by th�e Departienf Revenue withiin, 30, days of the, date filled iin below., ' <br />City or County Roseville <br />ty or loolunty narne <br />I If C <br />hip <br />Vftldi - Dowd <br />ft* - Orgu*400" <br />Vallowl — Howd Mims to Orgiouzatm ID, <br />Le oh&ftd afaw <br />CVW — City, & CAUnly <br />WOUM <br />Ire =M 111,11111-71111-1 <br />gnature et Person, receiving application <br />—T- <br />Maill th�is application to'. <br />A <br />Department of Revenue —Gaming Divi , sior. <br />I <br />Mail Slation 33,151 <br />St. Paull, MN 551461-3315 <br />