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<br /> <br />~¡' i eX) ÜVh. . -'!'ö/ <br />. I' . ,..' /!,.-i!/ <br />I ,'-ïV\' (/,)¡ llii' '/ <br />, - ""',\ cJi) ~". ,.,t¡,'" ,I <br />APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT' - . <br />OFFICE OF A TIORNEY GENERAL <br />SFN 9338 (07-2003) <br /> <br /> <br />'/ <br /> <br />Application for: <br /> <br />ri Local Permit <br /> <br />.. 0 Charity Local Permit (one event per year) <br />Date(s) of ctivity <br />05 to 'It~' <br />Business Phone Number <br /> <br />Name of Non-profit Organization <br /> <br />) f¡ Lk) [: ", <br /> <br />Person Responsible for the Gam'n <br /> <br />£:1/ I <br /> <br />Business Address 80 <br /> <br /> <br />Mailing Address (if different) <br /> <br /> <br /> <br />(i L u <br /> <br />0 <br />Wn t1u+ <br /> <br />Check the Game(s) to be Conducted: <br /> <br />0 Bingo Ø-Raffle <br /> <br />C¡vty <br />-, 4-..£.$ <br /> <br />. Po r, Twenty-one, and Paddlewheels may be Conducted only by a Charity LoCal Permit. <br />Dpalendar Raffle D Sports Pool 0 Poker. 0 Twenty-one. <br /> <br />.s <br /> <br />¡ "Ð.? t- <br /> <br />D Paddlewheels' <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br />Retail Value of <br />Prize <br /> <br /> <br />¡."\k $ <br /> <br />1".] 0 ----- <br />" /' <br />() /'\,71 <br />cr" ',jU <br />--- <br /> <br />v <br /> <br />Game Type Description of Prize Retail Value of <br /> Prize <br /> $ <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> (Limit $12,000 per year} <br /> Total: $ 71ì/).-- <br /> <br />Game Type <br /> <br />Description of Prize <br /> <br />þ;, ,-',. <br />. <br /> <br /> <br />InF-ded use, of paming proceeds: ~y -e d 15> Ab,: -f ¡ J j } (Î.:J"v' \ '; , . --+ "7 (l AlA SJ1.-S! r A{:jß' i \ b t..1"::' ,,' <br /> <br />'\ .9- i, 'yo rI ,,1'1 irJ) ~L-" <br /> <br />Does the organization presently have a state gaming license? ~ DYes - If "Yes,. the organization is not eligible for a local permit or charity local <br />permit and should call the Office of Attomey 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 3D? ~ No 0 Yes - If.V es.. <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? ¿; Dyes - If "Yes," <br />indicate the total value of all prizes previously awarded: $ " This amount is part of the total prize limft of $12,000 per year, <br /> <br /> <br />op Exeç:utive OffiCial <br />,",;'-;//"" "é"""""~/ <br /> <br /> <br />