d. Raffle permit/St. Benedict's - Laserfiche WebLink

SFN 93:38 (02-:2002) Application for: I~r'Local Permit * [] Charity Local Permit (one event per year) Name of Non-profit Organization Date(s) of~Activity Person Responsible for the Gaming Operation, Including Disbursement of Net Income Title (C~,.~ Business Phone Number Business Address City State Zip Code Mailing Address (if different) City State Zip Code Name of Site Where Game(s) will be Conducted Site Address State Zip Code I County s oq" J Check the Game(s) to be Conducted: * Poker, Twenty-one, and Paddlewheels may be Conducted only by a Charity Local Permit. [] Bingo [~Raffie r-]calendar Raffle [] Sports Pool [] Poker * [] Twenty-one * [] Paddlewheels * 3ESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED Retail Value of Game Type Description of Prize Prize Retail Value of Game Type Description of Prize Prize (Limit S&O00 per year) Intended uses of gaming proceeds: ~--0'c~t~OLA'''~ ~,.~dO.~t3? ~}l"0¢4/'0-irrb', FY-xc~-~''F~L-~(-~L'' Ck-~ SO_~J,'~5 Does the organization presently have a state gaming license? ,~ No [] Yes - If "Yes," the organization is not eligible for a local permit or charity local permit and should call the Office of Attorney General at 1-800-326-9240. Has the organization received a charity local permit from this or another city or county for the fiscal year July 1 through June 30? ~ No [] Yes - If "Yes," the organization does not qualify for a local permit or charity local permit. Has the organization received a local permit from this or another city or county for the fiscal year July 1 through June 30? J~No [] Yes - If "Yes," indicate the total value of all prizes previously awarded: $ . This amount is part of the total prize limit of $6,000 per year. t S~fL~ganiza~cutive Official Title , Business Phone Number 701-~ - z~z~ z..