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Pull-Tabs <br />Use of Profit 0 9 <br />To help support act 12v 10ties a u,rsing homels, hospitals and miedical scholarship <br />DiobtKiftlir's I.Joerm ogr am <br />DftMbutW FnM Mom QWnWing; Equipment Acquimild <br />3 <br />r <br />I affirm all 1n1for atilon submitted to the Board is true. I affirm all financial information submitted to the Board is trqe,,v,' <br />accurate,l and complete. ,accurate,, and completa, W. Av, <br />ti <br />0� 11/21/ 8 4. <br />Chilelf Executive Officer Signature Date IChi ef, Execulift CKIM Signature <br />- ------------- I - I <br />---------------- <br />ACKNOWLEDGEMENT OF NOTICE BIY LOCAL GOVERNING BODYA- <br />Naime lot' Wmal Governing &Xly (City, or cati <br />OOPMM& <br />Signature ol,Mateo eivingAOpIll <br />Ti ift <br />Township Name (Mu31 be nofified when County is the approving body) <br />Signature, of Person Receiving Application <br />AL <br />Date Received Tifle <br />CG-OW120-02' 1518) Whiiile Board C81niary — Board reluril to Gruani78tion fn comoletill shaded Area% <br />Date Receiveld <br />