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<br /> <br />"1( IU' W ~(,I1fI~~.~ ~J¿ -1:-V~IjL~t:~¿; <br />APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMlTlaj~; Lf)Ufr}lllúæ' JoY <br />OFFICE OF ATTORNEY GENERAL <br />SFN 9338 (07.2003) <br /> <br />Application for: <br /> <br />~ocal Pennit <br /> <br />* 0 Charity Local Permit (one event per year) <br /> <br />Date(s) of Activity (eh,J J.DD~ <br />, to ¡-e <br /> <br /> <br />or! <br /> <br />Business Phone Number <br />111 341- 1./130 <br />Statp Zip Code <br />IV/) 0802-/ <br />Zip Code <br />// <br /> <br /> <br />TItle <br /> <br />, , <br /> <br />State <br />/I//J <br /> <br />Site Address <br /> <br />, . <br /> <br />I ( <br /> <br />( I <br /> <br />City <br />leu.! <br /> <br />Check the Game( ) to be Conducted: <br />0 Bingo ~ffle <br /> <br />State Zip Code <br />J ¡} -S~80 21 <br /> <br />* Poker, Twenty-one, and Paddlewheels may be Conducted only by a Charity Lòeal Permit <br />OCalendar Raffle 0 Sports Pool 0 Poker * 0 Twenty-one * <br /> <br /> <br />0 Paddlewheels' <br /> <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br />Retail Value of <br />Prize <br />S Ö 06 <br /> <br />Game Type <br /> <br />Description of Prize <br /> <br />Game Type Description of Prize Retail Value of <br />Prize <br /> 1$ <br /> . I <br /> I <br /> <br /> <br />I <br /> <br /> <br /> <br /> (limit $12,000 per year) <br /> Total: $ ;}('f). tJ 0 <br /> <br /> <br />/j¡(9,¡/! 6p r <br /> <br />aJ/ <br /> <br />Does the organization presently have a state gaming license? !SJ:.No 0 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 /> <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? l;2tNo <br />the organization does not qualify for a local permit or charity local permit <br /> <br />Has the organization received a local permit from this or another city or county for the fiscal year July. 1 through June 3D? c;INo 0 Yes . If "Yes.. <br />indicate the total value of all prizes previously awarded: $ . This amount is part of the total prize limit of $12, aao per year. <br /> <br />Dyes - If "Yes,. <br /> <br /> <br />Date <br />It).- 7 - 0 ..¡ <br /> <br />Title <br /> <br />1.:r..!5- <br /> <br />Business Phone Number <br />-347- tI? 30 <br />