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<br />RECEIVED <br /> <br /> <br />DEe ~ 8 2005 5~~tnif -flO. 00 ClppliCtttiM{eL{lu}aJr1e.$ <br /> <br />APPLlCAT~~~~ce~E'RMrr OR CHARITY LOCAL PERMIT~h'.' c,~f!AV~ <br />OFFICE OF ATTORNEY GENERAL wH cOI'rIp,d-i1 ~ppJI(:O..\ Irll <br />SFN 9338 (07-2003) 1f8c})- <br />* 0 Charity Local Permit (one event per year) <br />Date(s) of Activity <br /> <br />to ~-..;2 <br /> <br />o~ <br /> <br />v <br /> <br />Business Phone Number <br />lJ/- pi.. 9'3 ';;' <br />State f\ Zip S9ge <br />11 ( t::J . ..:::> -g- /0 ..:J-7 <br />State Zip Code <br /> <br />City <br /> <br />Check the Game(s) to be Co ducted: <br /> <br />o Bingo ~affle <br /> <br />countyc.~' <br /> <br />* Poker, Twenty-one, and Paddlewheels may be Conducted only by a Charity LoCal Permit. <br />o Calendar Raffle 0 Sports Pool D Poker * D Twenty-one * 0 Paddlewheels' <br /> <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br /> <br />Game Type Description of Prize Retail Value of Game Type Description of Prize Retail Value of <br />Prize Prize <br /> O() $ <br />$ 500"- 1'1 <br /> o't,.; , aO.O~ <br /> ~~O - <br /> IbO 0,0 <br />If I Of) () ;;~ <br />1/ 00 00 <br />It ~r; (">0 <br />Ie <br />{{ <br />I( <br /> (Umit $12,000 per year) <br /> Total: $ 13 SJ'" 00 <br /> <br />l~ndedU$~Ofgf"~~' ~~!::;1:N:f' <br />t}.(7FfJ d1t~-4::iz;'JZu.c'4rl ~---- ~ - -' <br />, . t' <br /> <br />Does the organization presently have a state gaming license? ;gJ..No Dyes - 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 1-800-326-9240. <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 chari~ 19ca1 permit. <br /> <br />Has the organization received a local permit from this~r ariot!l.er city or county for the fisCal year July 1 through June 30? !5(] No ' Dyes - If "Yes," <br />indicate the total value of all prizes previously awarded: $' . This amount is part ofthetotaf prize limit of $12,000 per year. <br /> <br />Ii Ii <br /> <br />