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CITYOFROSEVILLE <br />GAMBLING LICENSE APPLICATION <br />(FOR ORGA1�lIZATIONS APPLYING FOR EXEMPTION FROM STATE LICENSING) <br />URGANIZATION INFORMATION <br />Name �� ��-��i� ��_ t-���_ \)���i . 'i�.v x� � ��rz-�I <br />Telephone Number �l�i�� --2��c���, <br />Address �� �(� I �i �.�,1�/f�/�i l U�,� i� l.�l � <br />Organization's Purpose � ��� � � - � �— �- <br />C�,AMRi.Tj�,C� F.VF.NT TNF(1RMATinN <br />N e w 0 r Have Previously Applied `� <br />Location of Event in Roseville .� /L( h�! L�,A%ii�'�=, 7�l>f�) �1 ✓�- <br />Date of Gambling Activity ��C�_► . l� , i.C�l`) I <br />Estimated Time of Activity � i.L,C= � r�r"7 <br />Dollar Amount of Total Prizes to be Awarded �E� �v�Z% �'�, <br />Funds Will be Used for �`. b�.c�.�, � i-�:.� �� ���- �- r u�`�-t- <br />APPLICANT INFORMATION <br />Name 1� A--�' 1 l� L�.;; .. ���C�_�_�=.��,) <br />Telephone Number _,.,,; �� 7 - <br />Signature <br />Date % � /�. - c:u / <br />LICENSE FEE $25.00 <br />� ,�� `% � �7 J C��� <br />WITHIN TEN (10) DAYS OF FILING ANY REPORTS WITH TI� CHARITABLE <br />GAlV�LING CONTROL BOARD, THE ORGAI�IZATION SHALL FILE A COPY OF SUCH <br />REPORTS WITH THE CITY OF ROSEVILLE, AS REQLTIRED BY SECTION 125.060 OF <br />'TI� CITY CODE. <br />c bfFcelwpwin\exmptgam wpd <br />