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Value of Priz,es Expenses Profit <br />Bingo <br />Y <br />Raffles <br />Paddlewheels <br />Tipboarlds <br />Pull-Tabs <br />is <br />Distributor From Whom Gambling Equipment Acquired <br />I affirm a 1 1 i�n�f ormation su bim itted to the Board is true,, accu- attirm al <br />rTte,, and complete. true, accurate,, and complete. <br />I� * a <br />zz. <br />DistTibUtOT'S Ucense No. <br />6'hiie IExecuatiive Officer Signature L Date Chief Executive Officer Signature Date <br />ACKNOWLEDGMENT OF NOTICE BYLOCAL GOVERNING. BODY <br />Name of Laical Governing Bod County) <br />OmEiD I <br />siginatuirr,of2 oiin Hlei3eivi ion, <br />ers inj <br />CG-00020-01 (4/861 White � Board <br />Pink — Organization <br />TowinshipiNarne (Must be notified when County is the approving body) <br />Signature, of Person Receiving Application <br />Date Received Title <br />— I I - I . / I <br />Canary- — Board returns to Organization to keep <br />Gold — City or County <br />a <br />