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<br /> <br />5Lt~tlIif 4110- 00 ~ljca1itJil feLf#1J; <br />APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT~C,~ J'--.1.' <br />OFFICE OF ATTORNEY GENERAL fl,/lfn CDthpdi! IJ.fP I~ 16')'1 <br />SFN 9338 (07-2003) <br /> <br />Application for: <br /> <br />o Local Permit <br /> <br />Busine~\D~ 'Bf2)~ b~ <br /> <br />Mailing Address (if different) <br />~m~ <br /> <br />Name of Site Where Game{s) will be Conducted <br />~\0\~ <br />City <br />\t\~~W <br /> <br /> <br />x <br /> <br />\C1S <br /> <br />* IiJ Charity Local Permit (one event per year) <br />Date(s) of Activityf;r't\~r.:h 1~,Jt.t~- AI~!frl . ~ t,dlU h We <br />N\.D.Y. lq O'2tCJ:5~- Q.ct <br />T~ <br />r~ <br />CityHo f2ACE <br />City <br /> <br /> <br />State <br /> <br />Zip Code <br /> <br />Name of Non-profit Organization <br /> <br />~ ~ <br /> <br /> <br />fT <br /> <br />Person ~2t~)Ze ~am~, Including Disbursement of Net Income <br /> <br />Check the Game(s) to be Conducted: <br /> <br />o Bingo 0 Raffle <br /> <br /> <br />W\.cu.' r\.J {l ~ <br /> <br />Zip Code Coun~ <br />5 GA-SC! <br /> <br />" Poker, Twenty-one, and Paddlewheels may be Conducted only by a Charity LoCal Permit. <br />DCalendar Raffle D Sports Pool ~ Poker" 0 Twenty-one" <br /> <br />o Paddlewheels' <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br />Retail Value of <br />Prize <br /> <br />Game Type <br /> <br />Description of Prize <br /> <br />Game Type Description of Prize Retail Value of <br /> Prize <br /> $ <br /> (Umit $12,000 per year) <br /> Total: $ <br /> <br />YD\<:.e1.2.... <br /> <br /> <br />Intended uses of gaming proceecls: <br /> <br /> <br />tV) bo n <br /> <br /> <br />Does the organization presently have a state gaming license? f)(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 1-800-3~9240. . <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? ,p(NO 0 Yes - 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 3D? JdNo Dyes - If "Yes; <br />indicate the total value of all prizes previously awarded: $. . This amount is part of the total prize limit of $12, o&Jtier year. <br /> <br /> <br />fficial <br /> <br /> <br />