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<br />;tf 3 g/} <br />. 5l.1.~lI\if 4110. DO aw1i(itb'biI-fet,- ~ <br />APPLICATION FORA LOCAL PERMIT OR CHARITY LOCAL PERMrr~h' e,~'!!A. J.u.!..' <br />OFFICE OF= AlTORNEY GENERAL lli/r. CDtlIp,di1 o..pp l~ Irll <br />SFN 9338 (07-2003) <br /> <br /> <br />* 0 Charity Local Permit (one event per year) <br />Date{s) of Activity <br />& e.:t-. %. ,;1005 to <br /> <br />Application for: <br /> <br />Local Permit <br /> <br />Name of Non-profit Organization <br /> <br /> <br /> <br />6 <br /> <br />Person Responsible for the Gaming Operation, Induding Disbursement of Net InCOme <br /> <br />Title <br />~~ <br /> <br />Business Phone Number <br /> <br /> <br />Mailing Address (if different) <br />'3 b.:2 '"1'1~ p. <br />Name of Site Where Game{s) will be Conducted <br />1:1<.. <br />City <br />~ <br /> <br /> <br /> <br />City <br /> <br />State <br /> <br />Zip Code <br /> <br /> <br />State <br />/J~ <br /> <br />Zip Code <br />5: CJ...7 / <br /> <br />~ <br />Site Address <br />'~,}7.~~ <br /> <br />State <br />7!~ <br /> <br />Zip Code <br />5J'tl ~ 7 <br /> <br />County <br />~ <br /> <br />Check the Game{s) to be Conducted: . Poker, Twenty-one, and Paddlewheels may be Conducted only by a Charity LoCal Penn it. <br />o Bi~go KI. Raffle DCalendar Raffle 0 Sports Pool 0 Poker. 0 Twenty-one * <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br />Retail Value of <br />Prize <br /> <br />Game Type <br /> <br />Description of Prize <br /> <br /> <br />$ 500- ()V <br /> <br /> <br />'7..(' 00 <br />91 00 <br /> <br />o Paddlewheels. <br /> <br />Game Type Description of Prize Retail Value of <br />Prize <br /> $ <br /> . <br />v <br /> (Umit $12,000 per year) <br /> Total: $(., 7S; a() <br /> <br />Intended uses of gaming proceeds: (:~.A ~A ~~ ,,-,,~ <br /> <br />Does the organiZation presently have a state gaming license? E!tNo 0 Yes - If "Yes," the organization is not eligible for a local pennit or charity local <br />pennitand should call the Office of Attorney General at 1-800-326-9240. <br /> <br />Has the organization received a charity local pennit from this or another city or county for the fiscal year July 1 through June 30? E:iNO Dyes - If"Yes," <br />the organization does not qualify for a local pennit orchari~lecal permit <br /> <br />Has the organization received a local permit from this'~r aliot!1er city or county for the fisCal year July 1 through June 30? BNo' 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 />eial <br /> <br />,p Ii <br /> <br />