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<br />::jI- 3g6 5l.1.~fl\it 4110- 00 appli C1tIiDil-{el- = <br />APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT~h' c,llf!' :. .~. <br />OFFICE OF ATTORNEY GENERAL wH CDthp}d-i1 Afpl'CO-l'N1 <br />SFN 9338 (07-2003) <br /> <br /> <br /> <br />Application for: <br /> <br />~ocal Permit <br /> <br />/(P3 <br />Mailing Address (if different) <br /> <br /> <br />to C1 /1 g r!5 <br /> <br />Site Address '.J.-. <br />1170";- 38-+1- Sr 'S <br />State Zip Code . <br />y\JD ~~oc.I{ <br /> <br />" Poker, Twenty-one, and Paddlewheels may be Conducted only by a Charity LoCal Permit. <br />o Calendar Raffle 0 Sports Pool 0 Poker" D Twenty-one" D Paddlewheels' <br /> <br /> <br />(\D- ~ e.- <br />Check the Garne(s) to be. Conducted: <br />o Bingo ~ Raffle <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 /> <br />Game Type <br /> <br />k' <br /> <br /> <br />( \ <br /> <br />00 <br /> <br />4f€ <br /> <br />, r <br /> <br />" <br /> <br />I, 6'00 <br />, , <br /> DO <br />\.-, bU <br />, ' SD <br />i. L!..-ttif:> 6--0 <br />" <l-o-<o ~ 6u <br />l\ DISft--' S~rl~ 6" <br /> ?CA ~K- ' <br /> <br />'1 <br /> <br />1< <br /> <br />Description of Prize <br /> <br />Retail Value of <br />Prize <br /> <br /> <br />~ <br />fOO <br />6-0 <br /> <br />50 <br /> <br />30 <br /> <br />'<1s'~ <br /> <br />(limit $12,000 o~ year) <br />Total: $ (P.O 0 <br /> <br /> <br />"t- <br /> <br />Does the organization presently have a state gaming license? ~ 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 1-800-326-9240. <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? ~ 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? ~. Dyes - 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 />~ <br /> <br /> <br /> <br />Business Phone Number <br />5-4S0S- <br />