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APPLiCATiON FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT M.~-- ~o <br /> OFFICE OF A'I-I'ORNEY GENERAL <br /> <br /> Application for:. '~,ocai Permit * [] Charity Local Permit ?ne ~e~t p~r~e.~ <br />I Name of Non-pro~t emanation I DAte(s) o_f?tivity z,i ' <br /> Person R~ponsible, for/,z ~v/~ T~ tt~eL~ 5 i'i6Gar~ing operation, Including Disbursement of Net Income T'j~e/~(~ Vi ~) I/'~'j ' ' Busine~s/_..l~__~% -51 --] '''~Ph°ne Number <br /> Business Address .... Sta~e Zip C <br /> <br /> Mailing Aclclress (if different) City State IZip Code <br /> <br />;hec~e Game(s) to be Conducted: "Poker, Twenty-one, and Padcllewneels may be Conducted only by a Chanty Local Permit. <br />L~Bingo/-, [] Raffle []Calendar Raffle [] Spor[s Pool [] Poker' [] Twenty-~ne * <br /> <br />[] Pacidlewneeis * <br /> <br />}ESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br /> Game Type Description of Prize <br /> <br />Retail Value of <br />Prize <br /> <br /> Retail Value of <br />Game Type Description of Prize <br /> Prize <br /> <br /> $ <br /> <br />Total: <br /> <br /> (Limit SB.c00 Der year) <br /> <br />$ <br /> <br /> lntendedu_Aesofgamingpro,creeds: Y~'~ '(~./~ ~'~ S~01'~ ~.,~ ;' ~,~;t~[~l~'~'~ \~/~d Jm <br /> ~o~ t~e o~an~on ~resently ~ve a ~t~t~ g~ming ~i~ns~o ~ Y~ - If "Y~/' t~ org~niz~on is not eligi~l~ for a Io~ ~rmit or <br /> <br /> H~ t~ o~iz~tion re~ive~ ~ ~a~ ~o~I ~e~it from t~is or ~o~r ~ or ~oun~ for t~e fis~l y~r July ~ t~roug~ Jun~ SO?~o ~ Y~ - if <br /> "Y~," ~ org~n~on ~o~s not ~uali~ for ~ Io~ ~e~i~ or ~a~ Io~ ~. <br /> <br /> Has the o~ani~tion re~ived a Io~1 pe~it from ~is or another c~ or ~un~ for the fis~l year July 1 through June 30? ~o ~ Yes - If '~es," <br /> indi~te ~e total value of all prizes previously awaked: $ . ~is amount is pa~ of the ~tal pdze limit of 56,000 pedyeac <br /> <br />Sign~ of Orga~~~ Exe~e O~cial Da,e // Title/' f Business Phcne Number <br /> <br /> <br />