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' :'~,~i~''W~ (~,I, ~/,~"~, ~,' ' <br />APPLICATION FOR A LOCAL pERMIT OR CHARITY LOCAL PERMIT~'~u ~"'~""~' ~6~ <br />OFFICE OF A~ORN~ GENE~' ~ <br /> Appli~tion for: ~1 Pe~it * ~ Charity Lo~l Pe~it (one event per year) <br /> <br /> Name of Non-proW[ Organization Date(s) of Activity /'~t~ ! <br /> <br />Pemon Responsible for ~e Gaming Operation, I~duding Disbursement of Net In.me ~fle -- ~ B~in~ Phone Numar <br /> <br />Busine~ Addre~ Ci~ S~ ~p ~e <br />Mailing Addr~ (if di~erent) Ci~ S~ Zip ~e <br />Name of Site Where Game(s) will be ConduCed S~e ~dr~ <br /> <br />Check ~e Game(s) ~ be ConduCed: * Poker, Twen~ne, and Paddlewheels may be ~ndu~d only by a Chad~ L0~I Pe~it. <br />~ Bingo ~ Ra~e ~Calendar Ra~e ~ Spo~ P~I ~ Poker * ~ Twen~e * ~ Paddle~ls * <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 Prize Retail Value of <br /> Prize <br /> (Limit $12,000 per year) <br /> Total: $ <br /> <br />~~'~ ~;1~ i ~ ~ . , <br />D~s ~e organi~on presently have a s~ gaming Ii.rise? ~ No ~ Yes - If ~es,' ~e organi~fion is not eligible for a Io~1 pe~it or ~afi~ I~1 <br />~it and should ~11 ~e ~ of A~omey General at 1-80G~2~9240. <br /> <br />Has ~e organi~fion m~ived a ~afi~ 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 "Yes," <br />· e organi~fion d~ not quali~ for a 1o~I pe~it or ~afi~ Io~1 pe~i~ <br /> <br />Has ~e organi~fion re~ived a Io~1 pe~it from ~is or ano~er d~ or ~un~ for ~e fis~l year July 1 ~rough June 30? ~ No ~Y~ - If ~es," <br />indi~te ~e to~l value of all p~ previously awarded: $ . ~is amount is pa~ of ~e total pdze lim~ of $12,000 per year. <br /> <br />Business Phone Number <br />~1-2~ z- 78 ~ '7 <br /> <br /> <br />