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<br />1. <br /> <br />'. 51.\.~ll\if 4110. OOappliCltliM feLd <br />APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT~h' Co~ 'I"'J.' <br />OFFICE OF ATTORNEY GENERAL ~/Jf cOIllpJd-i'1 (),fP 'COol ,1)'1 <br />SFN 9338 (07-2003) <br /> <br /> <br />~~I Permit <br /> <br />. 0 Charity Local Permit (one event peryeari1r?A5 <br /> <br />Application for: <br /> <br />N~me of Non~profjt Organization /, / / ' <br /> <br />I Co pltt(J W,' d /: <" <br /> <br />per~n Resp~nsibJe for the Gaming Qpera,tion, Induding Disbursement of Net Income <br />1"(....1'/( 1~ 0/= P"'-.v,,- or; ",-SJ.. ;--4 r <br />Business Address /) 'I- <br />A ':6.>J ~pl1 5 5i <br /> <br />Mailing Address (if different) <br /> <br /> <br />Date(s) of Activity ____ <br />.Fe b 11 doobto feb L/ JOOI; <br />Title j <br />Viqfr... -6-/r.,.:;. <br /> <br />Business Phone Number <br />,;ns -.3 2/Y - .2:JS.:.J! <br />Slale L <br />11 D..~ <br />Slate <br /> <br />Zip Code <br />~d-O 7 <br />Zip Code <br /> <br />C'ty <br />~LjkVl / <br /> <br />City <br /> <br />Name of Sjte IYhere Game(s) wiil be Co'l'1ucte<l/ <br />[Y1 bd<<n 'YF.1.(1/Dr (~"'if-or <br />City <br />CI'1 b/R'1 <br /> <br />Check ;!!>'-Game(s) to be Conducted: <br />~ingo ~ <br /> <br />Site Address ) I h <br />f>1b#~.... l"\ Yo...J.(, <br />Slate k Zip Code Co~ty' <br />J... . CCi....55 <br />.. Poker, Twenty-one, and Paddlewheels may be Conducted only by a Charity LoCal Permit. <br />o Caiendar Raffle 0 Sports Pool 0 Poker' 0 Twenty-one' <br /> <br />o PaddJewheels' <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br />GameType Description of Prize Retail Value of <br /> Prize <br />/3.'n",c> 1-'---'0.>- p~.,,~, $ 3 () o. <br />-<. ''"'-14P. <br />k'~ /)//<'- /,..,..,.... 4' <br />..P.~~/'<-:. .. 0} PS, f-tJo, <br /> <br />Game Type Description of Prize Retail Value of <br /> Prize <br /> $ <br /> , <br />.. <br /> , <br /> (Limit $12.000 per year) <br /> Total: $ 9o(}, c7CJ <br /> <br />Intended uses of gaming proceeds: <br /> <br /> <br />9 <br /> <br /> <br />/"/ <br /> <br />fl~se.'?-..-/ /1; ~G. -< <br /> <br />Does the. organization presently have a state gaming license? [~'~;R)-" Dyes - If "Yes," the organization is not eligible for a local permit or charity local <br />permit and should caillhe Office of Attorney General at 1-800-326-9240. <br /> <br />Has the ~rganization receiv~d a charity local pennitfrom this or another city or county for the fiscal "year July 1 through June 3D? [B~. Dyes ~ If RYes," <br />the organization does not qualify for a local permit or chari.~ .Ipeal permit ." <br /> <br />Has the organization received a local permit from this-~r another city or county for the fisCal year July 1 through June 3D? D No . l~lY'~ _ If"Yes," <br />indicate the total value of all prizes previously awarded: $ );,P O. . This amount is pari of the total prize limit of $12,000 per year. <br /> <br />Si9/~(~ <br /> <br /> <br />p Executive Official <br /> <br />Date <br />/-3-CJb <br /> <br />Title <br />;/;c <<. ff.... s; <br /> <br />