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book number': <br />Attach copy of certificate, <br />11 b. Number of active meimbers <br />:13 C) <br />17. Name of Chief Executivie Officer <br />C I ( ( R <br />Title <br />n <br />t., V, <br />Business Phone Number <br />I ( I*)- ) 41 94,31S <br />1 161.. Number of years in existence <br />CK 6 <br />19. Name of establishment where gambling will be <br />clonducted <br />21 �. City, State, Zip <br />M, <br />CG-0001 -02 118/86) <br />Note: If less than four years, attach <br />evidence of three years <br />existence. <br />18. Name of treasurer or person who accounts for other revenues <br />of the organization. <br />WL-1- <br />IM <br />Business Phone Number <br />,( 4 �i i ) 4k`( -331 <br />20. Street address (not P.O. Box Numberl <br />a56s ti, s..<<i, „ <br />22., County where gambling preMses is located) <br />VIVI I in all S S 11 1 <br />White Copy-Board <br />Pink-Local Governing Bodly <br />