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CITY OF ROSEVILLE <br />GAMBLING LICENSE APPLICATION <br />(FOR ORGANIZATIONS APPLYING FOR EXEMPTION FROM STATE LICENSING) <br />N�e __ � � .�� � . � -� 20 9 <br />Telephone Number �i �� ��� — �C� pg <br />Address 4 � � °� ��� � <br />Organization's Purpose <br />New (YV � <br />Location of Event in <br />/ <br />� <br />r Have Previously Applie�l_1✓/ _ <br />`�' Q.. / <br />u <br />Date of Gambling Activity <br />Estimated Time of Activity ��jf,J�'�'L �/ '� <br />v <br />Dollar Amount of Total Prizes to be Awarded '� ZSdJ � 3SF.r7 �'' <br />�� � <br />Funds Will be Used for �C ��G���/ �/�l�i� <br />�PLICANT INFOR�IATION� <br />Name , R <br />Telephone <br />Signature <br />� <br />Date �— —O� <br />LICENSE FEE $25.00 <br />WITHIN TEN (10) DAYS OF FILING ANY REPORTS WITH THE CHARITABLE <br />GAMBLING CONTROL BOARD, THE ORGANIZATION SHALL FILE A COPY OF SUCH <br />REPORTS WITH THE CITY OF ROSEVILLE, AS REQUIRED BY SECTION 125.060 OF <br />THE CITY CODE. <br />C:bflicclwpwinkzmptgun wpd <br />