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CITY.OFROSEVILLE <br />GAMBLING LICENSE APPLICATION <br />(FOR ORGANIZATIONS APPLYING FOR EXEMPTION FROM STATE LICENSING) <br />��]:Zl1_�►1f►A_ 11�1 [�7►�1►1�[�1.��% 11�1 [�l� <br />Name ��=� � ��- C� �.���c �� � L <br />Telephone Number _�`�I �o � i '�-� `�e� � <br />Address \� i � L�c�}- �.'-�� �c�, � �3�� �\�o �'`�1s�1 ���1_� <br />Organization's Purpose ��t� � �r.? M <br />GAMBLING EVENT INFORMATION <br />`�i c�� � ��5� --� � �,. �'.�1- . ���:�-� <br />New �% Or Have Previously Applied <br />Location of Event in Roseville ���15� �,, ��U��- � ���� � � ��.> a`j��'U ��o✓'�)'Z-' <br />���VC' r�1 ��C�I � `�'�y _ . <br />Date of Gambling Activity �%GVe:rn1�� �� , �.'�'' �.. <br />Estimated Time of Activity � � • � ' � � �� <br />#�� <br />`Dollar Amount of Total Prizes to be Awarded ���'���� .. C� �=' <br />Funds Will be Used for �.�- ��h�rl t�e�v �__ �� `�U{� ��`'�, �� a-1,-k> 1�.. <br />APPLICANT INFORMATION � �� �, � �� <br />Name �-� 1-�;�� c _ f�� � <br />Telephone Number lQ � l l�'� (- � i�,C lv <br />Signature �-''"/,/'/.�� �,P.�°�.J <br />Date � -/� - a� <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:bffice\wpwinkxmptgam wpd <br />