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CITY OF ROSEVILLE <br />GAMBLING LICENSE APPLICATION <br />(FOR ORGAI�TIZATIONS APPLYING FOR EXEMPTION FROM STATE LICENSING) <br />� ► : \ : � \ \ •:1/: •\ <br />I . - . <br />Telephone Number �� ��, ( p � � `� � � �'� <br />r�u J ° <br />Address ��`"t L� {'� U�IM ���� /-'�1'�- • ��i�Y� <br />' 1�'�d�'L- � G'�•• °t J �'' � <br />Organization s Purpose ; L�� ��� � <br />GAMBLING EVENT INFORMATION <br />New 0 r Have Previously Applied �v <br />Location of Event in Roseville ���' � U�'e- ��/�`�� b� '{ �� ��' �i � �'�l�' <br />Date of Gambling Activity �1 � I� I C( <br />Estimated Time of Activity (� ���� ��; �J ���� <br />Dollar Amount of Total Prizes to be Awarded ���� , � U�' <br />Funds W;11 be Used for ��,��;�.P�i� (��l•i� Lti���V� <br />APPLICANT INFORMATION � <br />� <br />Name � '11�-i �� I/l %�.v�� <br />� <br />Telephone Number T, . `p � � 1 �;� 4 � ' V/ � f� `2 <br />a <br />Signature L� l/U1G� )`�� <br />, <br />Date �� � � � � � <br />LICENSE FEE $25.00 <br />WITHIl�T TEN (10) DAYS OF FILING ANY REPORTS WITH TI� CHARITABLE <br />GANIBLING CONTROL BOARD, TI� ORGANIZATION SHALL FILE A COPY OF SUCH <br />REPORTS WITH THE CITY OF ROSEVILLE, AS REQUIRED BY SECTION 125.060 OF <br />TI� CITY CODE. <br />C b�te'.�cpw'm�.e�mpl$am ��pd <br />