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<br /> <br />~ I V" vV' \'/VUy J ! w...""........" - ~ ~ p......'--.... JY....1...f.jV:-V J0/l.. <br /> <br />APPLlCA nON FOR ~ LOCAL PE-RMIT OR CHARITY LOCAL PERM'I~C:tS'J Ct,JurtiLf tiu&titf <br />OFFICE OF ATTORNEY GENERAL <br />SFN 9338 (07-2003) <br /> <br />Application for: <br /> <br />Local Permit <br /> <br />. D Charity Local P it <br /> <br />Date(s) of Activity\JUl1t a ) <br />to <br /> <br /> <br />b <br />I <br /> <br />Name of Non-profit Organization <br /> <br />Rc t?; e Vet /Ie <br /> <br />Person Responsible for the Gaming Operation, Indu <br />JDfJrJ L r:TZ-- <br /> <br />Business Address <br /> <br /> <br />j r- CS50 C. <br />ing Disbursement of Net Income <br /> <br />Title <br />fill f) f\ <br /> <br />eR <br /> <br />Business Phone Number <br />10 lelf ;/-~;;!OO <br />State Zip Code <br /> <br />City <br /> <br />Mailing Address (ff different) <br />- yo 8c>x:1Q 7 <br /> <br />Name of Site V!he~ Game(s) will be Conducted <br />Re d f\. j y e l~ It . 0 <br />City <br /> <br />City <br /> <br />State <br /> <br />Zip Code <br /> <br />o <br /> <br />Site Address (l~ <br />/pjIo I It; 'Ice; () A-Ve. <br />Zip Code Coun~ <br />!3 50 1 (l irS- 5 <br /> <br />.., Poker, Twenty-one, and Paddlewheeds may be Conducted only by a Charity LoCal Permit. <br />DCalendar Raffle D Sports Pool D Poker' D Twenty-one' <br /> <br /> <br />I? Ceo'U0d-s <br /> <br />e:S1 -rP..- V <br /> <br />State <br /> <br />N. <br /> <br />Check the Game(s) to be Conducted: <br />D Bingo _ -)i(:f Raffle <br /> <br />D Paddlewheels' <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br />Game Type DeSCriptiO~ of Prize Retail Value of <br />Prize <br />((a. FFf r'. I/j" O'-{ DLtitl Ke I $ IOe?, 00 <br />eMbRoideRer! <br /> - <br /> - <br /> , <br /> - <br /> - <br /> <br />Game Type Descriptio n of Prize Retail Value of <br /> Prize <br /> $ <br /> --- <br />- - <br />- <br /> (Umit$12,OOO per year) <br /> Total: $ <br /> <br />Intended uses of gaming proceeds: <br /> <br />&d-121L< J <br />I (I <br /> <br />(}.#'<--:L~C<.1 <br /> <br />1-6 t'2- UU-R, o:'Jd-O <t- ~'ft" <br />u <br /> <br />u-iJ~i:o <br /> <br />Does the organization presently have a state gaming license-? IKl No _ Dyes ,- If "'Yes,. the organization is not eligible for a local permit'9r c;harity Jog:ll. <br />permit and should call ihe Office of Atto"mey Ge'neral at 1-80"0":326-9240. ~. . .: ',";' , <br />. . . 'H'" <br />Has the orgariiza~on received a charity local permit from this or another elfy or county fo; the fiscal year' J~JY 1 through June 30? ~ No DYes _ If~Yes," <br />the organization does not qual_ify for ~ local permit or d1arity local permit . <br /> <br />Has the organization received a local pennlt from this or another city or county for the fiscal year July 1 through June 3D? ;gJ.No Dyes _ If "'Yes," <br />indicate the total value of all prizes previously awarded: S . This amount is part of the total prize Jjm~ of $12,000 per year. <br /> <br /> <br />lion's Top ExeOJtive Official <br /> <br /> <br />Date <br />'J- 1(; ~ <br /> <br /> <br />Business Phone Number <br />