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11 i V <br />diG <br />Ma a-I .1 ;1. rm, i I, i mi 3 -j, i ui <br />S t; tj -1- m 5.1. 6 33 15 <br />61] 2. 9 Y <br />ONF *4 MY <br />LAWFUL GAMIST.TNG APPI.TCATTON <br />a I lt-owiud orpatlzn tioni 111y, 111111) C' 11"PI-Owd o t11.1p 1j),jilicat101, cotidl("t <br />g n ii , n n in <br />othetr thail L-1 1.11ce-11se-A 'LL'.111te 011( (1,1Y liel:, cc-j1eiidcnr yetar fol. 'not more thaii 12 hod <br />is i,r tiuli-e itre rewulli- tit. -in 60 deny .7 betwi-rim the clate th;1t the city/ Cot. lit y sign.c; the <br />W <br />apI-)1ic;tt-ioii trind the d.nce of the off-si, <br />,.t(.3, goniblAng, inchide a wal.ver from the city/count)r <br />wa I v i i,i g -1 tiall 6 0-da y id, is tri p p i-ov a I) e r ixi (I a <br />e 11r.1tit clebarly or type. Attzieb a, copy of t1lie jease for the off-site premises. <br />* AI-Viet- I-eviow, the app licc-littoii 01.1. be i-ettirtied tio the organization with ;ipprov.-i-I or <br />dem,JA hid1c;ited helow. <br />,ACKNOWLED,G'EMM OF NOTICE BY' LOCAI GOVERNING BODY <br />11 hereby acknowledge having belen served with notice that this application will be reviewed by the Charitable <br />Cambling Controil Board and, if approved, will become effective 60, days from the date of receipt <br />0oted' below,) urt - 11 1 ess a reel uLion of the 11 oea governing body is plasis,e,d Lhat specifically disalliorm such <br />activity and a copy of that riesiolut,ion, is, received by the Charitable Cambling Control Board within 60 days of <br />the below, noted date. The ciLy air county may choose to waaive the 60-day acknowledgement period by resolution. <br />Attach the. written waivier to this reqluest. <br />If site is located within a township, items 9 and 10 must be icornplet,ed i'n addition to the county signature. <br />1 96, Name of township <br />PO. Signature of person, recleiving appilication I Title <br />'FOR BOARD USE ON <br />Approve e,d Denied <br />Executive Secretary . Date <br />Charitable Gambling Control Board <br />r ,, 4" 4 , 4 a-, , t ­' . ­ ( �' / 47 1;1 / C, P N <br />