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<br />~ <br /> <br />;ffJff _ <br />5l.1.~tnit 4110- 00 appliC1tliDil-{el- = <br />APPLICATION FOR A LOCAL PE'RMIT OR CHARITY LOCAL PERMIT~h' c,~~ .I'__~' <br />OFFICE OF ATTORNEY GENERAL WJr. CDI11pdi1 t),fPJI(:O-I'N1 <br />SFN 9338 (07-2003) <br /> <br /> <br />Application for: <br /> <br />local Permit <br /> <br />* 0 Charity Local Permit (one event per year) <br />Date(s} of Activity <br />[De-to ~e-v" 12t.1"Q 5 /IY 1/)(>> 6 <br />1ll{e . 8usin~ Phone Numbi;J <br />\/t"~$'. /dEle Lf ri- 5 535 <br /> <br />CityCa..-tJ(.\A."'-.vsAiv Zi~ ~ (p <br />C~ State Zip Code <br />GU...\fJLvL.tLV N \) 5 ~o '3 ~ <br />Site Address <br />Ru...-l.. ~ c; a..v& V\ -e.,V N f) , <br />S~t7- . Zip Code Cou!J.\Y <br />1V.t> 'S ~ tJ '$ (p \..: ~ S' 5 <br /> <br />Name of Non-profit Organization <br />N I!J 1Ca.- LiA- th~ C, ~ u-vc..-h. <br /> <br />Person Responsible for the Gamin <br />e_J~-t(\I\ \\~ <br /> <br />Busine;s t;dr;-SS <br /> <br />Mailing Address (if different) <br />OvtQf:1 ~ <br /> <br /> <br />Operation, Including Disbursement of Net Income <br />t..L l \ '-'L ~ <br /> <br />Name o,f Sjte Where G~me(s) will be Conducted <br />~ N 0 V'd<..... L u... 1i..... €-\{"Q v- <br />Citj /' \ <br />\7 O-\{' OL '(\~ <br /> <br />Ir"f' 5't 5'G <br /> <br />l'lb:L 1 16 5 r c; E <br /> <br />C ~-Lk <br /> <br />Check the Game(s) to be Conducted: * Poker, Twenty-one, and Paddlewheels may be Conducted only by a Charity LoCal Permit. <br />o Bingo ~ Raffle DCalendar Raffle 0 Sports Pool 0 Poker * 0 Twenty-one * <br /> <br />o Paddlewheels * <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br />Game Type <br /> <br />Description of Prize <br /> <br />Retail Value of <br />Prize <br />IJtJ t (; c. <br /> <br />5 () , ,,'Co , <br /> <br />c26, CO <br /> <br />Game Type Description of Prize Retail Value of <br />Prize <br /> $ <br />~ <br /> ~1;l5 per year) <br /> Total: $ t t?C/ <br /> <br /> <br /> <br />Intended uses of gaming proceecls: <br /> <br /> <br />-I- <br /> <br />Does the organization presently have a state gaming license? dNo Ves - 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 1-80dC~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? viNo Dves - If.Ves," <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 a~omerpty or county for the fisCal year July 1 through June 30? ONe. ~Yes - If"Yes," <br />indicate the total value of all prizes previously awarded:;; .1/LfJ I .. f'. This amount is part of the total prize limit of $12,000 per year. <br /> <br />~ t;. <br /> <br />Signature of Organization's Top Executive Official <br />/-, <br />f <br /> <br /> <br />