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<br />DEe, 9 2005 . ~ <br />- 5~~tnif -fl0.ooClppliCtttiM'feL='I,Jt$ <br />~~T .~ CASS COUNTY COMMISSION, ~ ,.', <br />l~ ' APPLlCA TION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT~.' c,~f!A <br />~{L .-=t OFFICE OF ATTORNEY GENERAL with CDI'rIp,d-i1 ~ppJico.tirll <br />y~~ ':.<.. 4,'=>L} SFN 9338 (07-2003) ....k' ~ -'1. <br />o,.^'O&~'O ~11 ifl J <br />Application for: <br /> <br />Ch.ocal Permit <br /> <br /> <br />RECEIVED <br /> <br /> <br />Name of Non-profit Orga' tion <br /> <br />.s: ~' <br /> <br />Mailing Address (if different) <br /> <br />C <br />Check the Game(s) to be Conducted: <br />o Bingo ~Raffle <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 />* 0 Charity Local Permit <br />Date(s) of Activity <br />;y; <br />11t! <br /> <br />(one event per year) <br /> <br />o Paddlewheels' <br /> <br />Game Type Description of Prize Retail Value of <br />Prize <br /> $ <br />0 <br /> (Umit $12,000 per year) <br /> Total: $~tXlf/* <br /> <br />Intended uses of gaming proceeds: /etl ~ /eJ./ I;' , <br /> <br />rAt'.. <br /> <br />h~f,.r;{/ A r- L <br />{ , <br /> <br />Does the organization presently have a state gaming license? [E' No Dyes - If "Yes," the organization is not ~Iigible for a local permit or charity local <br />permit and should call the Office of Attomey 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 charitx I.ocal permit <br /> <br />Has the organization received a local permit from this or ariot!ler city or county for the fisCal year July 1 through June 30? ctNo. 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 />ecutive Official <br /> <br />Ii ii <br /> <br /> <br /> <br />),(~ <br /> <br />Business Phone Number <br /> <br />~, f -~~f': <br />