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<br />s l.l.blllif 4110- 00 ~liCltlitJil.#-= <br /> <br />APPLJCATION FORA LOCAL PEi~Mlf OR CHARITY LOCAL PERMIT~h' c,~'!fU J'ul.' <br />OFFICE OF ATTORNEY GENERAL W/r CDhlpdi! ~.pp 1C{).llrll <br />SFN 9338 (07-2003) . ~ 3 '10 <br />Application for: %.-. Local Permit * D Charity Local Permit (one event per year) <br />Date(s) of Activity <br /> <br /> <br /> <br />(2 ltb <br /> <br />eY' <br /> <br /> <br />Mailing Address (if different) <br /> <br />~/E- <br /> <br />/)0 :;1.0 IAlIN, J.~ ~Ob S <br /> <br />Business Phone Number <br /> <br />0$5- <br /> <br />City <br /> <br /> <br />City <br />h.R.Co-f-I6-"-" <br /> <br />Zip Code <br />!:'~J' 0 79 <br />Zip Code <br />'7.0 77' <br /> <br />/1' <br /> <br />Site Address <br /> <br />)'J? oJ e 17 <br />Check the Game(s) to be Conducted: * Peker, Twenty-one, and Paddlewheels may be Conducted only by a Charity LoCal Permit. <br />D Binge 1i?J Raffle DCalendar Raffle 0 Sports Pool D Poker * 0 Twenty-one * <br /> <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 />1-0, <br /> <br />'r <br />County <br />C.~S5 <br /> <br />D Paddlewheels' <br /> <br />~ <br /> <br />Game Type Description of Prize Retail Value .of <br /> Prize <br /> $ <br /> (Umit $12,000 per year) <br /> Total: $ _':5S- " ,- lID <br /> <br />Intended uses of gaming proceeds: <br /> <br />/Ueecfy <br /> <br />;:::: op/e. <br />, ) <br /> <br />1 "t.-t..-+A. <br /> <br />Does the .organization presently have a state gaming license? 81 No Dyes - If "Yes: the organization is not eligible for a lecal permit or charity local <br />permit and should call the Office of Attorney General at 1-800-326-9240. <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? ~No Dyes _ If "Yes," <br />the organization does not qualify for a local permit or charity local permit. <br /> <br />~a~ the organization received ~ local p~rmit from this or anotfi.er city .or coun~ fer the fi:,CaI year July 1 thro.ugh. J~ne 30? !2rNo. Dyes - If "Yes: <br />mdlcate the total value of all pnzes previously awarded: $ :. . ThiS amount IS part of the total pnze limit of $12,OOOper year. <br /> <br /> <br />ecutive Official <br /> <br /> <br />C, 1- () / s-'1 <br />