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�Premilses Address City State Zip County <br />2100, Snel--1--ing Ave., Roseville, Mn . 55113 Ramsey <br />LAI <br />'.-',Expens**'eis, and <br />Pro i <br />oss Co'st"of Priz'6s <br />Game Yes No Gr Rece"i6ts <br />Tipboards <br />Pul�l-Ta s <br />X <br />X <br />X <br />61 <br />FI'4 <br />ii 30"VE "-w, <br />36 <br />1.419 <br />M a' tkit Va 16 Ik <br />;ginaVre of Pers�on Receiving appli <br />Title. Date Receiv <br />CIG-00020-01 (16/87) White Board <br />Pliink —'O,rgainiization <br />Signature of Person Receiving Application <br />km <br />Canary — Board returns to Organization to complete shaded areas, <br />Gold — Cjtv or County <br />