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Address <br />MAX <br />Chief Executive Officer's Name <br />AM <br />T'ypie 0 Organization <br />0 Fraternal 11 Veterans, <br />�D Religion PC, Other Nionprofilt Origanizatiol <br />Name of Premises Where Activity Will Occur <br />ZIL I/? <br />Premises Address <br />M <br />• <br />�S� <br />jddlewhelels, <br />City, Coun(Vill, Stat�ie, Ziip Code <br />INN' Al en <I,= <br />Ivei //4t;- <br />Gross Receipts T�Value of Prizes Expenses <br />'a <br />Distributor" s License No. <br />bi litted to the Board is true, accu- I affirm a�ll, financial Information submitted to the Board is <br />true, accurate,, and completell, J <br />A. <br />Chief �Executive Offilceir Siq <br />Chief Executive Officer Signature <br />ACKNOWLEDGMENT OF NOTICE BYLOCAL GOVERNING BOD N <br />fill'. <br />sicelvin fication <br />A WAR �-- <br />�'ownslhip arne( ust lie notified when County is the approving body) <br />Signature 011 Person Receiving Application <br />CG-00020-01 (4/86j, White — Board Canary — Board returns to Organization to keep <br />Pink — Organization Giold — City or County <br />