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A=VA#AFAF',WS0 .- <br />4MMEWAL <br />Type of Organization <br />El Firaternal 13 Veterans <br />El Riefigion W Oth�eri Nonprolf it Orig an ization <br />Narne of Preni Where Activity Witl 101ccur <br />Y12ij / 19140P <br />Premises Address <br />/41 <br />Games Yes. <br />Bingo <br />Raffles <br />Paddlewheels <br />Paull -Tabs <br />Use! of Profit <br />1101i <br />AM <br />No Gross Receipts <br />Diistr,ibiut�or From Whom Gambling EquipmentAcquired <br />WILSILi <br />Distributor's license No. <br />I af'f irm all information submitteld, to the Board is truei, accu-, I affirm all financial 'information submitted to the Board is <br />rate, and complete. I,i truei,, accuratei, and complete. <br />41 <br />. AKANSlff�Zr <br />Chief Executive Officer Signature <br />=0 <br />Name of L Bo or' County) <br />(Covor" ing Illy ISEV tL-� <br />Stiarri=rle o1 on Fk9c Applicatio, <br />L I <br />71tV <br />Titte Date Received <br />77 <br />Township Name (Must be notified when County is the approving body) <br />Signature oaf Person Receiving Application <br />a <br />CG-00020-01 14/8611 White — Board Cana rq — Board returns to Organization to keep <br />Pink, — Organization Gold — City or County <br />a <br />