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If <br />Ga.tibling License, Application <br />iy,pe olf Applicaltion, 0 Class A, lZaass 8 1:1 Class C C1 Class D <br />Yes I0 No 22. Is gambliniq premises located within city limits? <br />XYes I13 No, 21 Are all gambling activities conducted at the premisies listed in #18 of this application? If not, complete a separate <br />mplication for each Premises (exce t raffles) as, al separate license is required for each Rrernlsvo. <br />I Yes VNo 24. Foles, organization own the gambling premises? If no, aftaich copy of the lease with terms of at least one year, <br />and attach a sketch of the, premises indicating what portion, is being leased. A lease and sketch are not required <br />for Chiss D aDDlilca,tionis. <br />2,5. Amount of IRenit Per <br />Mon'th or Bingo Occasion <br />$ IdPMPUft I <br />26. Do, you plan on conducting bingo, with this liicense? If yes, give days and times of bingo occasions. <br />Day Time IDay Time Day Time <br />28. insurance Company Name, Inot agency name) <br />30. Lessior Na� e 3 1. Address <br />_4PLQ%,1 mm 10L <br />FW <br />GAMBLING SITE AUTHORIZATION <br />By my sig nature below,, local law enforcement officers or agents of the, Board are hereby authorized to enter upon the site at any <br />time gambling is being conducted to observe the gambling and to enforce the, law for any unauthorized game or practice. <br />BANK RECORDS AUTHORIZATION <br />By my signature, below, the Board is hereby authorized to inspect the bank records of the gambling bank account whenever <br />necessary to fulfill requirements of current', gambling rules and law. <br />416• Name of City or County (Local Governing Body) If site is located within a township, item 47 must be completed, <br />in addition to the county signature. If township is not organized, <br />count v must sign. <br />Signature of per'son I recleiving application <br />x <br />Title <br />4. rL <br />Date received (60 day period <br />begins from this date) i e) <br />47. Name of Township <br />Signature of person receiving application <br />48. Name of person dle,liverinig application to Local Governing BodylTitle <br />CG,-,00101 -,03 (3/891) White Copy-Board Canary-Appliciant Pink-Local Governing Body <br />Page 2 of 2 <br />