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AUG-08-2002 09�31 FINANCE <br />CITYOFROSEVILLE <br />6514902292 P.02 <br />GAMBLING LICENSE APPLICATION <br />(FOR ORGANIZATIONS APPLYING �Q� EXEMPTION FROM STATE LICENSING) <br />ORGAI�ATION INFORMATION <br />Name <br />� � �'�✓k <br />n <br />!SJ <br />Telephone Number ��.�.� — � � � � � � � <br />Address i �� �� � �' � C, f f s� >`t'Y� �'� � �i <br />Organization's Purpose � SiS � vJ�i/ ( U �vi Gw� ��.� ���i�.�- �G�� l�yc��'�( <br />t �� <br />���1VG EVEN� INFORMATTON <br />New Or <br />Location of Event in Roseville <br />Have Previously Applied x <br />ti <br />C�,��,�- Co� �►�� ��y ��va �M <br />J <br />Date of Gambling Activitv �C'�o�`r �i a'�d� <br />Estimated Time of Activity (4�_% O� ��'"^ ""` � � �� .4 � �^ � <br />Aollat ,Amount of Total ��azes to be Awarded �% v� �`{��, i�,C�C'� ��, V� (� <br />Funds Will be Used for 1���� (/'� l'�vt���l / 1`� N� �_..�6�/�fl� 1��'��°���-S <br />APPI,TC'.ANT TNFn-ON <br />,�'42 ",T� � ✓ � 4. w .,� t <br />Name o �� <br />Telephone Number <br />Signature <br />Date <br />��s'1-- �rr1 -�'Y� <br />�-�-�--�� , <br />.�' �' �:� <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:bRwelwpwinleun��m.wpd <br />TOTAL P.02 <br />