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APPLICATION FOR A LOCAL pERMI~ OR CHARITY LOCAL PERMIT~'~° ~',x-x,~,~ <br />OFFICE OF A~ORNEY GENE~ <br />SFN 9338 (07-2003) <br /> <br /> Appli~tion for: ~ Lo~l Pe~it * ~ Charity Lo~l Pe~it (one event per year) <br /> <br />Name of Non-profit Organization Date(s) of Activityi~r~v./ i~ iI~ t(~y.C h I~ <br />P~erson Responsible for the Gaming Operation, Including Disbursement of Net Income Title ~ Business Phone Number <br /> <br />Business Address City State Zip Code <br />Mailing Address (if dlg~rent) City State Zip Code <br />Name of Site Where Game(s) will be Conducted Site Address <br /> <br />City State JZip Code J County <br />Check the Game(s) to be Conducted: * Poker, Twenty-one, and Paddlewheels may be Conducted only by a Charity LOCal Permit. <br />~Bingo [] Raffle r'Icalendar Raffle [] Sports Pool [] Poker ' [] Twenty-one ' [] Paddlewheeis <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br />Game Type Description of Pdze Retail Value of <br /> Prize <br /> <br />Game Type Description of Pdze Retail Value of <br /> Prize <br /> $ <br /> <br /> (Limit $12,000 per year) <br /> Total: $ ~0~ <br /> <br /> D~s ~e organi~fion pr~enfly have a s~ gaming li~nse? ~o ~ Yes - If ~es," ~e organi~fion is not eligible for a Io~1 pe~it or ~ad~ I~1 <br /> pe~it and should ~lJ ~e ~ of A~omey General at 1-80~32~9240. <br /> <br /> Has ~e organi~fion m~ived a ~ad~ 1o~1 pe~it from ~is or ano~er d~ or ~un~ for ~e fis~l year July I ~rough June 30? ~ No ~ Yes - If ~es," <br /> · e organi~on d~ not quali~ for a Io~1 pe~it or ~ad~ Io~1 peril <br /> Has ~e organ~flon re~ived a 1o~1 pe~it from ~is or angler d~ or ~un~ for ~e fis~ year July 1 ~rough June 30~ ~ No ~Y~ - If ~es," <br /> indi~te ~e to~l value of all pdz~ previously awarded: $ ~ O, OO . This amount is pa~ of ~e total p~ze lim~ of $1~ 000 per year. ~ <br /> <br /> , <br />Jsi~eofOr~sTop~fiveOffidalDate_ // j fle ~ Busine~ Phone Number J <br /> <br /> <br />