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0%' APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT <br /> 1'1 F�sl OFFICE OF ATTORNEY GENERAL. <br /> .s' SFN 9338(9-2009) <br /> • Application for Local Permit *®Charity Local Permit tone event per Year) <br /> Name of Non-profit Organization -Data(s)ofAWWty <br /> Werlodeo C.l■4o 4 4(2 l o o 14 to y tote lap iM <br /> Person Responsible for the.Gaming Operation and the Disbursement of Net income lute Business Phone Number <br /> kyav v Ict -Trtf,�,tuxer- 1 o t -a3$-OS(O. <br /> Business Address City State Zip Code <br /> Mailing Address(lf, event) City State Zip Code <br /> Gad 1 C C.o t\c d _t.,43 Cc 1 b, _ Sgo`1'7 <br /> NAN me of Site Where Games)will be Site Address <br /> me <br /> lyeY \0.`kti u tV'" r o 10:K u3 e - Nv e <br /> City State Zip Code County <br /> WeS�- Trcirgo �„ I'S8o'I S (I CS <br /> Check the Game(s)to T.aWucted: •Poker TWenty-one,and Paddlewheels may be Conducted only by a Charity Local Permit. <br /> 0 Bingo 12Raffia OCalendar Rattle El Sports Pool 0 Poker' 0 Twenty-one* d Paddlewheels' <br /> DESCRIPTION AND RETAIL VALUE OF PRLZES TO BE AWARDED <br /> Retail Value of <br /> Game Type Description of Prize Prize Game Type Description of Prize Retail Value of <br /> Prize <br /> 5o( o' c 5'0%oo G4L • Ut4t4e wte <br /> alms Masa par year) <br /> Total: $ <br /> Untended one's of Offing Pis: 4..U Y e i see r && `�Q 11LE-' tnl't TVt Y'ta_e fl <br /> CaSTT qr Sitp Qavr' C'rL I 1rG1�0 c•0 k 4t [I. <br /> Does the organization presently have a state gaming license? No 0 Yes - if"Yes,"the organization Is not eligible fora local permit or charity local <br /> permit and should call the Office of Attorney General at 1 6-9240. <br /> Has the organization received a charity local permit from this or another cIy or county for the fiscal year July 1 through June 30?ErNo 0 Yes- ff"Yes," <br /> the organization does not qualify tar 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? IN No [] Yes- If"Yes," <br /> indicate the total value of all prizes previously awarded:$ . This amount is part of the total prize limit of$12,000 per year. <br /> Signature of organizations T ExecuBve Offidai Date Title JBusrnessPhonehiumber <br /> —1 i)N3 I-701--711.-37n <br />