Laserfiche WebLink
I <br />FOR BOARD USE ONLY <br />INSTRUCTIONS.- 1. Submit requiest for exemption at least 30 day's prior to the occasion. <br />2. 'When icompleting form, do not complete shaded areasi. <br />3. Give the gold copy to the City or County. Send the remaining copies to the Board. The copies will bi <br />returned with, an exeimption number addied to the form. When your actty is concluded; complete A i <br />PLEASE TYPE f inancial informiation, sign and date the f lorm , and retu,rin to the Board within 30 days. <br />organization Nairne <br />► �Mia.iAM rJ <br />2,048 N'. H=Line <br />�ke Gross Receipts Value of Prizes <br />IMIS <br />useofwofit General P'arlish Revenue.: Maintenance of Church, Utilities, Benefit of Religiou <br />Distributor From Whom Gambling Equipment Acquired <br />I affirm a' infoy7natipiin <br />rate, I co t <br />Distributor's License No. <br />itted to, the Board is true, accu- I affirm all financial information submitted to the Board is <br />"I /- I /// ; I true, accurate,, and complete. <br />ool I <br />Chief Executive officer Signature L-r 0/ - 111�v Date' Chief Executive Officer S gnature Date <br />ACID '16WILE DGM . �ENT OF NOTICE BYLOCAL GOVERNING BODY <br />Name of Lapal IGovernling 4w <br />a V-1r %q 0 F <br />Siiginatuire of Per in I Aeceivin, <br />4A <br />ty oiir County) <br />DSEV I L-L-C <br />ication <br />Title Date Renctived <br />CG,-01010210-011 (4186) White — Board <br />Ptnk — Orgainization <br />Township Name (Must be notified when County is the approving body I <br />Signature of Person Receiving Application <br />Canary — IBoard returns to Organization to keep <br />Giold — City or, County <br />A"T <br />