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;;i',: ;' ;, APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT <br /> s, J OFFICE OF ATTORNEY GENERAL <br /> }. 4-"4 l' SFN 9338(07-2009) <br /> • Application for: .Local Permit *❑Charity Local Permit (one event per year) <br /> Name of Non-profit Organization / Date(s)of Activity j — 3 f- 1 C <br /> r' , <br /> C 41/1E! _ r '_/,. /'r to /- //s i aczt_ t'% '1 �f' /' Lam <br /> Person�sp sible for the Gaming Operation and the Disbursement of Net Income Title Business Phone Number <br /> j�-s^ 24_ //nS nes . /-,238'- t Zic <br /> Business Address ,c r Litt State Zip Code q <br /> / ' �7 4‘-'‘ ~ S / J e Litt Q cc ci s-e/ g 42 5' a?/ <br /> Mailing Address(if different) City State Zip Code <br /> y '5 9' 44.7 44.7 / s,/ s 1.04.vet ‘k KI _It P s e 77' <br /> Name of Site Where Game(s will be Con ted Site Address <br /> s ( "I ilei-Q <br /> City State Zip Code Coun <br /> 1-/-/A4� •,t i ? I2 �"8'e7, ., 5$ . <br /> Check the Game(s)to be Con : *Poker,Twenty-one,and Paddlewheels may be Conducted only by a Charity Local Permit. <br /> ❑Bingo ffle ['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 /> a...7 #://to. ist „sirs..trsisz4 0,2 a r, 0 , <br /> i ° a5o Piss <br /> , . <br /> (Limit$12,000 per year) <br /> Total: $ "�/5 0.00 <br /> y,►rn. oL <br /> .,-- <br /> Intended uses of gaming procpeds: /'I / 0 if ,i>% /7.K ) PCh " �u//�e,- <br /> /4.05.e-tie re/e.:,Ls•.e q- e e e 7e 1.1_x4 /2/°n9r�--c--.e.S <br /> Does the organization presently have a state gaming license?j214o❑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? o ❑ 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? 1211`i; ❑ Yes - If"Yes," <br /> indicate the total value of all prizes previously awarded:$LI/co.,oQThis amount is part of the total prize limit of$12,000 per year. <br /> Signet of Org `ation's p Executive Official Date Title Business Phone Number <br /> v <br /> ?--/z$3"— 1 X AP_s , <br />