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<br /> <br />--- i I (). (fJjJ Ltflf f ( Utti ~ll-j{L t&LWft j <br /> <br />APPLICATION FOR A LOCAL PE"RMIT OR CHARITY LOCAL PERMITfrtj:Y liJUMj 'CiiJJ"tit! <br />OFFICE OF ATTORNEY GENERAL J.t 3/Jtl <br />SFN 9338 (07-2003) , . --:tf I /- / <br />Application for: ~ocal Permit <br /> <br />Name of Non-profit Organization /.,1. <br />./" . / - I <br />-::;;r:::c ria. " "~ <br />Person Responsible for the Gaming Operation, Including Disbursement of Net Income <br />. LtJ1 <br /> <br />Z. <br /> <br /> <br /> <br /> <br />t}... <br />Check the Game(s) to be Conducted: <br />o Bingo ~ Raffle <br /> <br />City <br /> <br />.. 0 Charity Local Permit (one event per year) <br />Date(s) of Activity <br />reb. ~ft; J..D 0 s.' to Fe.h :2/;. .204r:;- <br />~ Business Phone Number <br /> <br />~ <br /> <br /> <br />City <br /> <br /> <br />c/ <br /> <br />* Poker, Twenty-one, and Paddlewheels may be Conducted only by a Charity LoCal Permit. <br />DCalendar Raffle 0 Sports Pool D Poker * 0 Twenty-one * <br /> <br />o Paddlewheels' <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br /> <br />Game Type <br /> <br />Description of Prize <br /> <br />Intended uses of gaming proceeds: <br /> <br />~. <br /> <br />() V.n1 e.,rl is <br /> <br /> <br />Game Type Description of Prize Retail Value of <br />Prize <br /> $ <br /> Total: ;Um~1~2:r year} <br /> L. <br /> <br /> <br />Does the organization presently have a state gaming license? ~ No 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 1-800-3T6-9240. . <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? ~o Dyes - If"Yes," <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 30? D 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 /> <br />ecutive Official <br /> <br /> <br />