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<br />. 51.t~Il\.it -1110. 00 appli(a;1iLJr1 {u- = <br /> <br />APPLICATION FORA LOCAL PERMIT OR CHARITY LOCAL PERMIT~h' r.,~'!ft }'__J.' <br />OFFICE OF AlTORNEY GENERAL W/( cOlllpdi! o.pp 'co.l'l"( <br />SFN 9338 (07-2003) .P(3qf <br />Application for: 0 local Permit . C3"Charity local. Permit (one event per year) <br />Name of Non-profit Organization Date(s) of Activity <br />C.CL';,S C,,,,-,, 1-h'~inll\U<J SOC~(.~ flu /9 :2(:0{;, to ()t,{ <br />PerSon ~onslble for the Gaming Operation, Induding Disbursement of Net Income <br />,:)" c.z' uk <br />Business Address <br />)36 <br /> <br /> <br />jl?, MJ b <br /> <br />Mailing Address (if different) <br />(J,O <br /> <br />Name of Site Where Game(s) win be Conducted <br />. . III k!..- <br />City <br /> <br /> <br />Title ~ <br />'sP$-'- E-\", <br />Coor ;, ( <br /> <br />Business Phone Number <br /> <br />70/- ;)..- <br />State Zip Code <br />1) S!070 <br />S,14te Zip Code 8 <br />ND sS'{)7 <br /> <br /> <br /> <br />Site Address <br /> <br />S'1,;tel) <br /> <br /> <br />County CCl S S <br /> <br />Check the Game(s) to be Conducted: <br />Bingo 0 Raffle <br /> <br />... Poker, Twenty-one. and PaddJewheels may be Conducted only by a Charity LoCal Permit. <br />o Calendar Raffle 0 Sports Pool 0 Poker' 0 Twenty-one' <br /> <br />o Paddlewheels' <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br />Game Type <br /> <br />Description of Prize <br /> <br />Retail Value of <br />Prize <br /> <br />Game Type Description of Prize Retail Value of <br /> Prize <br /> $ <br /> (Limit $12,000 per year) <br /> Total: $ <br /> <br /> <br />Intended uses of gaming proceeds: 01(0v' "'*' '^-~ ~ ~,&>I\ .PI- <br /> <br />Does the organization presently have a state gaming license? ~o Dyes. If '"Yes, - the organization is not eligible for a local permit or charity local <br />permit and shouid call the Office of Attorney General at 1-800-326-9240. <br /> <br />Has the organization received a charity local pennit from this or another city or county for the fiscal year July 1 through June 30? ~ DYes _ If-Ves,- <br />the organization does not qualify for a local permit or charity local permit <br /> <br />Has the organization received-a local permit from this or another city or county for the fiscal year July 1 through June 30? g1"JO Dyes _ If "Yes,- , <br />indicate the total value of all prizes previously awarded: S . This amount is part of the total prize limit of $12,000 per year. <br /> <br /> <br />Date <br />lo-'2..\-o~ <br /> <br />Title <br />Q ( i1S\(j..iW:- <br /> <br />