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CITY OF ROSEVILLE <br />GAMBLING LICENSE APPLICATION <br />(FOR ORGANIZATIONS APPLYING FOR EXEMPTION FROM STATE LICENSING) <br />ORGANIZATION INFORMATION <br />1Vame ir' �Z � �j �r' �1� i�, s -s�{t � GU �Ec: ,�:. �/� �-`�!Gr+:�/g 1 /o'U ..:�'J G ( �7� jv <br />Telephone Number ��� � � 7�,.��' ��� �� <br />Address '7.3��'' �C%��f�l���V� �T /�L%. �,;�L�y /L%!/_ �5��3? <br />Organization's Purpose �� =���-'� I//1 %/ o�+/ G�f Y-�r7 l�'t.tl, e�� :�::� <br />GAMSLING EVENT INFORMATION <br />New �/ Or Have Previously Applied <br />Location of Event in Roseville � J`�✓1 C,G� ��� �(� �������� �- <br />Date of Gambling Activity /�`J�f� /�L j¢• �� 1`� c`":'� "� <br />Estimated Time of Activity ��� �� ��� <br />Dollar Amount of Tota1 Prizes to be Awarded ��,� s 7'�4 •ti'r'�-�U <br />. <br />Funds Will be Used for �"��� �j�a �'���<�Y � Cr d'� �% < < � S• P � • �+'� ':�' } �y �= r"-. <br />APPLICANT INFORMATION <br />Name � a!'L1 �-== t`� G[.f..�N �1' f.�'�� <br />Telephone Number � 1 �- � � � �:j' ' � � �' ✓� <br />.- n . <br />Signature <br />Date � / � ~ �`��� <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: bffialwpwinkxm ptgem. wpd <br />