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<br />RECEIVED <br /> <br />DEe _ 9 2005 5u.brni-Hllo. OD ClppliCll:ftJi/{eL- ~ <br /> <br />[,fiiIj., APPLlCA~MN1~ PERMI'T OR CHARITY LOCAL PERMIT~h',' c,~f!A }'__.L' <br />:\<<) OFFICE OF= ATTORNEY GENERAL Wlr CDI'rIp,d-e' tl.pP lco..t lrll <br />';;"o;"of;~.;t SFN 9338 (07-2003) " . ~ '2t1~ <br />Application for: .g Local Permit * 0 Charity Local Permit (one event per year) <br />Date(s) of Activity <br /> <br /> <br /> <br /> <br />City <br /> <br />State <br /> <br />Zip Code <br /> <br />Site Address <br />c;c) <br />State <br />'tJ <br /> <br />* Poker, Twenty-one, and Paddlewheels may be Conducted only by a Charity LoCal Permit. <br />DCalendar Raffle D Sports Pool D Poker * D Twenty-one * <br /> <br /> <br />Id~,- <br /> <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 />o Paddlewheels' <br /> <br />Game Type Description of Prize Retail Value of <br />Prize <br /> $ <br />c. <br /> (Umit $12,000 per year) <br /> Total: $ Ld'J. ,;,) <br /> <br />Intended uses of gaming proceeds: <br /> <br />~t/e;{;?1 /17 <br /> <br />.;4('. ~~ ~/~vy ;4r/. <br /> <br />Does the organization presently have a state gaming license? 0 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? 0 No Dyes - If "Yes," <br />the organization does not qualify for a local permit orcharit~l~cal permit. <br /> <br />Has the organization received a local permit from this or anot!ler city or county for the fisCal year July 1 through June 30? 0 No ' Dyes - If "Yes," <br />indicate the total value of all prizes previously awarded: $ :' :' . This amount is part of the total prize limft of $12,000 per year. <br /> <br />op Executive Official <br /> <br />Ii Ii <br /> <br /> <br /> <br />