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CITY OF ST ANTHONY <br /> DEPARTMENT OF LICENSING <br /> Date: <br /> The following is an application for use of 3.2 beer in City <br /> FULL NAME OF APPLICANT: e4l-pm <br /> (Must work in St. Anthony o 'e n St. Anthony) <br /> ADDRESS: 0 CZo <br /> AGE: <br /> I certify that-I a a reside of St. Anthony or work in the City. <br /> a esponsible for conduct of his/her group. <br /> Signature of Applicant <br /> �n <br /> NAME OF GROUP: ( <br /> # IN GROUP: ti <br /> DATE: f:y'HOURS: //; o 6 00 <br /> TELEPHONE#: ;2 :�-7 6 7 7 <br /> $50.00 CLEAN-UP DEPOSIT: <br /> (You are responsible for Park Clean-up, the deposit will be returned after inspection of the <br /> Park) <br /> RECEIVED BY: O G G7 <br /> RETURNED: ' <br /> i - <br />