Laserfiche WebLink
FOR BOARD USE ONLY <br />Liconse Number <br />------------- <br />PAID <br />AM <br />CHECK# <br />D AT E <br />Ip I ILI LCI 51 L";q �k M W. W11 I Lej �k, <br />Yes 0 No 3. Have Internal Controls been submitted previously? If no, Please attach copy. <br />4., �nt ('Off i�c,ial, legal name o r�ganiza�tilon) 5., Business Address of Organization <br />=111-retz- <br />6�. City, Sita�te, Zip <br />8, Business Phone Number <br />evidence of three years <br />/0 existence. <br />17. lWarneofiChieflExecutive Offi <br />21. <br />Title <br />Blusiness Phone Number <br />Name of esta�blishim�ent where gambling will ed be <br />A <br />conduct <br />dp% — <br />M -0 <br />City,, Suate, Zip <br />CG-0�001 -02 (6/86) <br />White Coipy-Board <br />18. Na of treasurer or person who accounts for other revenues <br />a <br />f t organization. <br />WW_ <br />Title <br />iniess Phone Number <br />2101. Street address (not P.O. Box Number) <br />22. County (where gambling premises is located) <br />Pink-Local Governing Body <br />