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<br />Po Ih' )~g'lOt <br />5 Ll.~lI\if 411 (). OD O{Y(li (jjji~ &JJ); <br />APPLICATION FOR A LOCAL PE"i~Mlf OR CHARITY LOCAL PERMIT~h.. c,1lf!!A J' _ _.1.., <br />OFFICE OF ATTORNEY GENERAL /hie (:otllp,d-i1 App Ico-IlN1 <br />SFN 9338 (07-2003) <br /> <br /> <br />Application for: <br /> <br />01' Local Permit <br /> <br />Name of Non-profit Organization <br />C~~S COlA. \'"'Ii <br /> <br />H\ ~ tnYI( <br /> <br />.Nu <br /> <br />* D Charity Local Permit (one event per year) <br />Date(s) of Activity <br />QG,S 200~to )~ 566 <br />Title <br />1) lY e c..tv y- 8' &- <br />Zip Code <br />s[{07 <br />Zip Code <br />cr;;~07~ <br /> <br />Sou e-h <br />Person Responsible for the Gaming Operation, Including Disbursement of Net InCome <br />- VV"'O~ V\.el Se.-, <br /> <br /> <br />Business Address <br />1'5 '5 l Was t- VV\o..,tY'l <br />Mailing Address (if different) <br />~~ 1lCf <br />Name of Site Where Game(s) will be Conducted <br />'b 0 1\ VL V\ L..tA. U ~ ~ -e.- <br />City <br />\;J e S -+ t CA. v-, <br /> <br /> <br /> <br />c~<;s <br /> <br />Check the Game(s) to be Conducted: * Poker, Twenty-one, and Paddlewheels may be Conducted only by a Charity LoCal Permit. <br />D Bingo p( Raffle D Calendar Raffle D Sports Pool D Poker' 0 Twenty-one' <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br />Game Type Description of Prize Retail Value of <br />Prize <br /> L"" <br />Y'ccf { l-e... a u.'t ({::- $ \()OC)- <br /> v <br /> <br />o Paddlewheels . <br /> <br />Game Type Description of Prize Retail Value of <br /> Prize <br /> $ <br />~ <br /> (Umit $12,000 per year) <br /> Total: $ /OOcJ ~ <br /> <br />Intended uses of gaming proceeds: 1~vtJL l ^--'- ~ ~ ~ ~ S\..~p~ ft- <br /> <br />Does the organization presently have a state gaming license? 15ZI No Dyes - 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-~6-9240. . <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? MNO 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.~r allot!1.er city or county for the fisCal year July 1 through June 30? 00 No . Dyes - If "Yes," <br />indicate the total value of all prizes previously awarded: $ . ' .. . This amount is part of the totaf prize limit of $12,oOOperyear. <br /> <br />" h <br /> <br /> <br /> <br />,,~ <br /> <br />~ <br />r:=~,,( <br /> <br />