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CITYOFROSEVILLE <br />GAMBLING LICENSE APPLICATION <br />(FOR ORGANIZATIONS APPLYING FOR EXEMPTION FROM STATE LICENSING) <br />ORGANIZATION INF(ORMAT�dN <br />0 <br />Name <br />r <br />Telephone Number 1�1,� ��� � ��'�7 � <br />Address -�Q� ��'h J�4�.1" S�i i�l_1!1�A��i�S� N� ����'' <br />Organization's Purpose � ��YL0��1� Q �2 �.01/►-� �lL � �N UY1GS�%� ��N� `iP/� <br />GAMBLING EVENT INFORMATION <br />New Or Have Previously Applied k <br />Location of Event in Roseviile ��2�JLJl�Q- S�i1.�VY1� � �C, ^,� <br />Z(do i v'i � Gern {%P�� -. �, _ <br />Date of Gambling Activity N �(.�Q � <br />Estimated Time of Activity �j'Y� • <br />Dollar Amount of Tota1 Prizes to be Awarded ���� ���" '"`� ���— (����1�� ��00 <br />Funds Will be Used for �Vt�%j�lll�' ' ��,�- <br />�PPLICANT INFORMATION <br />Name ► �`1 V ��- <br />Telephone Number W!�'�I� �'�� <br />Signature <br />Date �� b� �� <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:bfTice�wpw•in4zmptgam wpd <br />