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11 ID. 0 a , OA4 ?. yaijitioll-1:-
<br /> fir. ;-.1,,," APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT
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<br /> OFFICE OF ATTORNEY GENERAL
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<br /> As„. .,N 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
<br /> Nora Welca / 0 - 1 i./ to j G- 11 - /4
<br /> Person Responsible for the Gaming Operation and the Disbursement of Net Income Titl9 Business Pho�nnec�Number
<br /> Business Address �- Cit State Zip Code
<br /> LP� t ) $ , s c". , u_R-4-/ 214)---- _5 a c)3,
<br /> Mailing Address(if different) City State Zip Code
<br /> YYletita va-. dS `f a2.nA St 5 :�ll� / rev . .i,175,,,...._
<br /> 27 .±-8/6_9
<br /> Name of Site Where Game(s)will be Conducted Site Ad ss
<br /> he..1 a`6.�.,7iL<� d---4_4_,,„,.> / X o / 7 a , �'G
<br /> City State Zip Code County
<br /> can.e 2 7// 5 d 3& ga :L.,
<br /> Check the Game(s)to be Conducted: *Poker,Twenty-one,and Paddlewheels may be Conducted only by a Charity Local Permit.
<br /> ❑Bingo p Raffle ❑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 /> L (. . , . (. / 4 0 , d o
<br /> 0 G,
<br /> (Limit$12,000 per year)
<br /> Total: $ , p 0.00
<br /> ■ I
<br /> Intended uses of gaming proceeds: - �i,-.-.4-zw fAL,,. _,/z i d.,,., 0 h- tti.-c' ,L ( —1' �: z(-,, i >'—,�
<br /> Does the organization presently have a state gaming license? r.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? r2f.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 Organization's Top Executive Official Date Title ; Business Phone Number
<br /> c o 1z.. ,��-a--r.�rr� 7 ! -PI Title
<br /> '70/- 4 5�4--ss 3S"
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