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91 Af f '11 la of' Parent Nonprofit Organization <br />All 101ccur <br />F--remlses,Address <br />=INGI'Mi & COI RDi C or F40SIEV= . M 55113 <br />Grioss Receipts Va�luel of Prizel <br />Bingo I I x <br />IF bees I I <br />Paddlewheels, I I <br />Tipboards E� w <br />IM a F1. ME <br />Jse' of Proifit <br />Profit <br />Distributor From Wham Gambling Equipment Acquired Distributofs License No. <br />I af'f'irm all infor ation submitted to the Board is true, accu- I affirm alh financial information submitted to the Board is <br />Name of Local Governing Bindu (City or Ciouinty) <br />signet rsofRieceiv4pp'icatio o <br />Title <br />— <br />CG-00020-01 44/86J Whilt,ie – Board <br />Pink – Organization <br />Township Name (Must be notiftedwhen County is the approving body) <br />Signature of Person Receiving Application <br />Z ived title <br />Date R I T' <br />^ , f <br />LI 8 (P <br />Canary – Boardl returns to Organization to keep <br />Gold – City or County <br />01- <br />