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<br /> <br />5" t.tbll\.if ",0. 00 (i{.4lljCiJjibilfel- = <br />APPLICATION FOR A LOCAL PE'RMrr OR CHARITY LOCAL PERMIT~ CJIIf!!A J". .J.' <br />OFFICE OF ATTORNEY GENERAL Wlrn tDrn.pJde~ fJ.pp lco.t 1m <br />SFN 9338 (07-2003) <br /> <br />Application for: <br /> <br />LiI Local Permit <br /> <br /> <br />* 0 Charity Local Perm it (one event per year) <br />Date(s) of Activity , <br />rr'j ;J...2 to If -,JJ -dS <br /> <br /> <br />~ 1''7 ,I <br /> <br />Business Phone Number <br />. U - 217~7~~? <br />State Zip Code <br />(VtJ <br />State <br />)/tJ <br /> <br />Zip Code <br />5J"/d7 <br /> <br />-- <br />/"'e-:.. (~{; <br /> <br />Check the Game(s) to be Conducted: <br />o Bingo ~Raffle <br /> <br />W.e) r 5:,~dlll$ /~C <br />Zip Code County <br />G4fS <br />" Poker, Twenty-one, and Paddlewheels may be Conducted only by a Charity LoCal Permit. <br />DCalendar Raffle 0 Sports Pool 0 Poker" 0 Twenty-one. 0 Paddlewheels. <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br />Game Type <br /> <br />Retail Value of <br />Prize <br /> <br />Description of Prize <br /> <br /> <br />Game Type Description of Prize Retail Value of <br /> Prize <br /> $ <br /> (Umit $12,000 per year) <br /> Total: $ 71nf9. /J() <br /> <br />Intended uses of gaming proceeds: z;,., (1 r~t/{ #1<",,'1$ -to fA e 5-q n/I: 1,.1 _~~,.,.y #,~ <br />, <br /> <br />Does the organization presently have a state gaming license? nJ-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 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 30? [2No 0 Yes - If.Y 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 30? 0 No [3Yes - 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 /> <br />Executive Official <br /> <br /> <br />Business Phone Number <br />ltJl-2 J1'.rft( <br />