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<br /> <br />If ~ . / II <br />. . C!/ / S cd 5~bmlf 4l1O.C()(l{Jpli(af,M {eL.{1ujai!ltto <br />, '. Col1: Uai.JJJ:J-dt <br />APPLICATION FOR A LOCAL PERMrr OR CHARITY LOCAL PERMIT~fh' ,"!fA J'o oJ-' <br />OFFICE oF' ATTORNEY GENERAL . WI cOI!lfd-i1off Ico-l,r(1 <br />SFN 9338 (07-2003) <br /> <br />. 0 Charity Local Permit (one event per year) <br /> <br />Date(S)OfAclivity/_1 -O/P f-.:2d-(J~ <br />to -~~ 0<1, <br /> <br />J <br /> <br />Business Phone Number <br />/"t1 / - t?l- '13' - c:; ,;z <br />. Slate C\ Zip COde <br />1(,IJ. 5ff/v3 <br />Slate Zip Code <br /> <br />Check the Game{s) to be Co' dueled: <br />08ingo ~flIe <br /> <br />'ttaAc.Jk/ <br />, countyC~/ <br /> <br />* Poker, Twen'ty-one. and Paddlewhee1s may be Conducted only by a Charity LoCal Permit <br />o Calendar Raffle 0 Sports Pool 0 Poker. 0 Twenty.me. 0 Paddlewhee's' <br /> <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br />{f <br /> <br />,,0 <br /> <br />Game Type Description of Prize Retail Value of <br />Prize <br />0 .~..dil~ $ <br /> C# 4'.../ /AO."< <br />- <br /> '. (Umit $12,000 per yea~ <br /> Total: $ /3 s,y () <br /> <br />Game Type <br /> <br />Description of Prize <br /> <br />Retail Value of <br />Prize <br />- Ci t.'J <br />$ _500.- <br /> <br /> <br />0"" <br />- <br /> <br />If <br /> <br />-:Sl.L{.C <br />160 <br />/0& <br />/00 <br /> <br />'Ol> <br /> <br />(J,n <br /> <br />if <br /> <br />OCJ <br /> <br />/, <br /> <br />i, <br /> <br />I, <br /> <br /> <br />; .- r. ~.-c.P./ . <br />t/ "/ <br /> <br />Does the organization presently have a state gaming license?;glNo 0 Yes ~ If "'Yes," the organization is not ~[igible for a local permit or charity local <br />pennitand should call the OflIce of Attorney G.;o"",1 at HlOD-32f5..9240. <br /> <br />Has me organization received a charity local permit from this oranolher city or county for the fiscal year July 1 through June 3D? ~rNo Dyes - ff"Yes," <br />the organization does not Qualify for a local permit o~ _chari!X.t~ permit <br />. .., <br /> <br />Has the organization received a local pennrt from this ora\lol!1.er city or county for the fiscal year July 1 through June 3D? ~No . Dyes ~ If"'Yes," <br />inaicate the total value of all prizes previously awarded: ~ . This amount is pari of the total prize limit of $12, 000 per year. <br /> <br />i> i; <br /> <br />Si~n~e. of ?rgan.~ti6n's l' ~ve Official <br />~ rV .;a , ;/ _ , <br /> <br /> <br />~1-tf)C,- <br /> <br />