c. Permit for raffle-Triple C 4-H Club

q f :+r' 4 PP APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT OFFICE OF ATTORNEY GENERAL 3 n SFN 9338 (9 -2009) Application for: "X Local Permit Charity Local Permit (one event per year) Name of Non profit Organization Date(s) of Activity T'C o \P' C• 4 Clvb N— a- t k to 1-196-a01,1 Person Res on le for the aming Operation a d the Disbursement of Net Income Title Business Phone Number Business g aa Statg Zip Code CC�Ussl�l, L� j \V` Mailing Address (if different) City State Zip Code Name of Site Where Game(s) will be Conducted Site Address City State Zip Code Cou ty W MO 58 ms Check the Game(s) to be Conducted: Poker, Twenty -one, and Paddlewheels may be Conducted only by a Charity Local Permit. o Bingo g Raffle ❑Calendar Raffle Sports Pool Poker Twenty-one Paddlewheels DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED Retail Value of Retail Value of Game Type Description of Prize Game Type Description of Prize Prize Prize laCC-\e- 11.°t 6 3an to vi.v1/4 tumn 512.000 per vii Total: Intended uses of gaming proceeds: 1, a► !,L C M `)Z ►....1+' f _V rf, .p" \'1we... c1�nic.�atl` cork iepo coaria skz C nos 5Rt Q y SYicu> I i eda�t �l fit' ow- c au b J Does the organization presently have a state gaming license? No Yes If "Yes," the organization is not eligible for a local permit or chanty local permit and should call the Office of Attorney General at 1-800- 2 9240. Has the organization received a charity local permit from this or another city or county for the fiscal year July 1 through June 30? No Yes If "Yes," the organization does not qualify for a local permit or charity local permit. Has the organization received a local permit from this or another city or county for the fiscal year July 1 through June 30? 031 No Yes If "Yes," indicate the total value of all prizes previously awarded: This amount Is part of the total prize limit of $12,000 per year. 1 Signature of Organization's Top Executive Official Date Title Business Phone Number