j. Bingo & raffle permits - Laserfiche WebLink

APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT g.~. ~o, ~ OFFICE OF ATTORNEY GENERAL SFN 9338 (02-2002) Application for:. [] Local Permit *FI Chadty Local Permit (one event per year) Name ef Non-o, rofit Organization I Date(s) of Activity 'erson Responsible for the Gaming Opemfion,,l~nc~uding Disbursement of Net Income 'l'itie Business Address ~ z City Name~ Site W,~re G/~me(s)wilLbe Conducted Che~ ~e Game(e) to be C~du~: ~ B~ngo ~e tBusiness Phone Number I ,~ Zip Code State Zip Code Site Address / State Zip Code County Poker, Twenty-one, and Padctlewnee~s may be C<3nducted only by a Chadty Local Permit. E]Calendar Raffle [] Spor[s Pool [] Poker * [] Twenty-one ' [] Paddlewheels * DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED Game Type Description of Prize Retail Value of Prize F I Retail Value of Game Type Description of Prize Pdze (Limit S6.000 per year) Tot ,t: Intended uses of gaming proceeds: Does the organization presently have a state gaming license? ~'"No [] Yes - If "Yes," the organization is not eligible for a local permit or c. harity local permit and should call the Office of Attorney General at 1-800-326-9240. Has the organization received a chanty local permit from this or another ~'ty or county for the fiscal year July 1 through June 30? ~ [] Yes - If "Yes," the organization does not qualify for a local permit or chadty local permit. Has the organization received a local permit from this or another city or c~unty for the fiscal year July 1 through June 30? ~ [] Yes - If "Yes," indicate the total value of all prizes previously awarded: $ , This amount is part of the total pdze limit of $6,000 per year. ~91~j~ture of,~rganization's Top Executive Official / - Date rBusiness Phone Number