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Gambling License Application <br />Ty pie of' Application: � Xiass,A 1 Class, B El Class C 00ass D <br />OYes DEN� o 28. Do you plan oni conducting bingo with this license? If yes, give days and times of bingo occasions: <br />Days Times <br />301. Insurancei Company Name 31. BonckVurrber <br />GAMBLING SITE AUTHORIZATION <br />By my signature below, local liaw enif orcement officers or ageinits of thie Board are hereby authorized to enter upon the site, <br />-2t any time, gambl�ing is being conducted, to observe the garniblinig and to enforce the law for any unauthorized game or <br />practice. <br />BANK RECORDS AUTHORIZATION <br />y my Signature below, the Board is heilreby authorized to inspect the bank records of the General Gambling Bank Accouni <br />® necessary to fulfill requiriernents of current gambling rules a�nid law. <br />OATH <br />Title of Signer, <br />Commandier <br />Date f tor <br />lk.-o , 012 . I <br />ACKNOWLEDGEMENT OF NOTICE BY LOCAL GOVERNING BODY <br />I �heir,eby ackniowledge recielpt of a copy of' this application. By acknowledging receipt,, I admit having been served with <br />notice that this application will be reviewed by the Charitable Gambiling Control Board and if approved by the board,, wil, <br />become effective 30 days f romi the date, of rielcieipt (noted below), unless a resolution of the local governing bodv is passe.4. <br />which specifically disallows such, activity and a copy of that resol�utioin is received by the Charitable Gambling Contra: <br />Board within 30 days of' the bel�ow note,ld date. <br />42. Name, of City or County (Local Governing Bodly) If site, is located within a township, item 43 must be completed, in <br />City of Roseville I aiddition to the county signature, <br />White Co►y-Boart! <br />43, Name, of Township <br />Signature of person receiving application <br />Q <br />00- <br />Cainary-Applicant <br />Pink-Local Governing Body <br />