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mo. OD kyle i�+� c� f <br /> ,,t�� � {;���,� APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT <br /> ,,,:,,,,,1,,t,' r) I; OFFICE OF ATTORNEY GENERAL <br /> •:ri w''�1 SFN 9338(07-2009) <br /> Application for: Local Permit *❑Charity Local Permit (one event per year) <br /> Name of Non- rofit Organization Date(s)of Activity <br /> or nfinal tip;►d►Ie Cilhio i - aWo) to i - 5-aoi <br /> Person Responsible forth,Gaming Operation and the Disbursement of Net Income Title Business Phone Number <br /> tcur4 W0t1 Direc-4or ( 70)) 0, 31-3z)4 <br /> Business Address City State Zip Code <br /> Mailing Address(if different) City Stat Zip Code <br /> 114651 L 1 5f Wheel and l�� folg <br /> Name of Site Wh re Gap (s)will be onducted Site dr ss <br /> E-Yylbc�n 3 1io(.CA+11tn a�l <br /> City 1� n S►Vb Zi6ro /,..I Courtty_ /f <br /> 1fYl C <br /> Check the Game(s)to be Conducted: *Poker,Twenty-one,and Paddlewheels may be Conducted only by a Charity Local Permit. <br /> M Bingo J Raffle ID Calendar Raffle ❑Sports Pool ❑Poker* ❑Twenty-one* ❑ Paddlewheels* <br /> DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> Retail Value of Retail Value of <br /> Game Type Description of Prize Game Type Description of Prize <br /> Prize Prize <br /> i-- , /74i) <br /> 0:K., ,..9 Le—9 ok- <br /> A z� s <br /> / 6, <br /> a , <br /> L-A---/L 5 / <br /> (Limit$12,000 per year) <br /> Total: $ 1.,gr • O 0.00 <br /> Intended uses of gaming proceeds: V d CACGhOYI rh �are P2et , G r N a,Si, ,S irc�' .,`n3 youb,(Lin 1 `- 1-yv) 64- GUI C st �J <br /> Y <br /> Does the organization presently have a state gaming license? Et No ❑Yes - If"Yes,"the organization is not eligible for a local permit or charity local <br /> permit and should call the Office of Attorney General at 1-800-326-9240. <br /> 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," <br /> the organization does not qualify for a local permit or charity local permit. <br /> Has the organization received a local permit from this or another city or county for the fiscal year July 1 through June 30? EI,No ❑ Yes - If"Yes," <br /> indicate the total value of all prizes previously awarded:$ . This amount is part of the total prize limit of$12000 per year. <br /> Sigga of Or ation' op Executive Official Date Title Business Phone Number <br /> // �--t Y--�___ /-�o •-/y R,� r 2%57-a.V._% V <br />