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SFN 9338 (02-2002) <br /> <br /> Application for: [] Local Permit * [] Charity Local Permit (one event per year) <br /> <br />Name of Non-profit Organization Date(s) of Activity <br />Pemon Responsible for the Gaming Operation, In~uding Disbumement of Net In.me Title ~ Business Phone Number <br /> <br /> Business Address Ci~ S~te Zip Code <br /> Mailing Address (E d~emnt) C~ ~ State Zip Code <br /> Nam~of ~ite ~hem Game(s) will be ConduCed S~e~ddress <br /> <br /> Che~ the Game(s) to be ConduCed: * Poker, Twen~-one, and Paddlewheels may be ConduCed only by a Cha~ Lo~l Pe~. <br /> ~ Bingo ~ Raffle ~Calendar Raffle ~ Spots Pool ~ Poker * ~ T~n~ne * ~ Paddlewheels * <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br /> Retail Value of <br />Game Type Description of Prize Prize <br /> <br /> ,, ¢0,°° <br /> <br /> Retail Value of <br />Game Type Description of Prize Pdze <br /> (Limit $6J~00 per ye.a~ <br /> Total: $ <br /> <br />Intended uses of gaming proceeds: ~01"o.. <br /> <br />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 <br />permit and should call the Office of Attorney General at 1-800c326-9240. <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? ~] <br /> No <br /> Yes <br /> If <br /> <br />"Yes," 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 30? [] No ~ Yes - If"Yes," <br />indicate the total value of all prizes previously awarded: $ j_~' .~, ~o . This amount is part of the total prize limit of $6,000 per year. <br /> <br />SignaLure of Organization's Top Executive Official <br /> <br />Title <br /> <br />Business Phone Number <br /> <br />(over) <br /> <br /> <br />