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l4.'+' t"fl <br /> APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT <br /> OFFICE OF ATTORNEY GENERAL <br /> r .-. A. .. <br /> s 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 /> Ciowbby U t\/7 2fo(*' to 0/0/Agivi <br /> Person Res 6nsible for the Gaming Operation and the Disbursement of Net Income Title Business Phone Number <br /> LeroA i lAintX ( 19 61615 —2053 <br /> Businesddress City Sta e Zip Code <br /> 1746 ib 011 St \NOIVer+00 i3tosq4.--615k* <br /> Mailing Address(if different) City State Zip Code <br /> Name of Site Where Game(s)will be Conducted S e Address <br /> i(N kerl70G -er ti Vttor Locker 4-I2... ilau a ,A�e <br /> City �1 Stat Code Cou ty <br /> NiokSon NI04� mss <br /> Check the Game(s)to be Conducted: *Poker,Twenty-one,and Paddlewheels may be Conducted only by a Charity Local Permit. <br /> ❑Bingo ❑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 /> TTfx7 00gelir i 1W Ir) <br /> vG&x• <br /> 110 pDQ(e <br /> P(060 Fru, <br /> (Limit$12,000 per year) <br /> Total: $ 0.00 <br /> Intended uses of gaming proceeds: Canal- c E,e a1 U <br /> Does the organization presently have a state gaming license? 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- 2 -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? lt 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? No El Yes - If"Yes," <br /> indicate the total value of all prizes previously awarded:$ . This amount is part of the total prize limit of$12, 0 per year. <br /> Signature of Organization's Top Executive Official Date Title Business Phone Number <br />