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Name of Pre Millses Where Activity Will Occur <br />Af J <br />4W <br />Pre,rnises Address <br />A <br />Games, L/Yes No, <br />City, County, State, Zip Code <br />Manalger"s-Name Phone Number <br />- I JiII s EMMMUM <br />l�f Other Nonprofit Organization (Check One� <br />0 URS Designation <br />0 inclorporated with Secretary of State <br />I® Aff Iliate, of Parent Nonprofit Organ Ization <br />MA/ <br />Gross Receipts Value of Prizes <br />Expenses <br />Distiributor From Whom Gambllinig Equipment Acquired Distributor's License No. <br />I affirm all information submitted to the Board is true, accu- I affirm ail financial Information submitted to the Board is <br />rate, and complete,. <br />truei, accurate., and complete, <br />Name c ocal GioverniPR-I, Mity or County) Towinship,N ame I Must be notified when County is the approving body) <br />ti <br />gnatureosbn Receiv Applicatio, <br />Signature of Person Receiving Application <br />IM <br />CG-000120-01 114,186) White — Board Canary — Board returns to Organization to keep <br />Pink — Organization Gold — City, or County <br />