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OFFICE OF ATTORNEY GENERAL ~ <br />SFN 9338 (07-2003) <br /> Application for: [] Local Permit * ~Charity Local Permit (one event peryear) <br /> <br /> Namep. f I'~on-pmfit Organizaaon <br /> <br />Person R~.~onsible~ for~ Gaming ~fion, Including Disbume~nt of Net tn~me <br />Busin~ Addre~ <br /> <br />Mailing Addr~ (if di~rent) , ~ <br /> <br />Name of ~ ~her~ Game(~ll ~ Condumed <br /> <br />Check the Game(s) to be Conducted: <br /> D Bingo J~],Raffie <br /> <br /> Date(s) of Ac'd.vity <br /> '13tle Business Phone Number <br /> <br />C~t~ State Zip Code <br />Cib State Zip Code <br /> <br />* Poker, Twenty-one, and Paddlewheels may be Condumed only by a Charity Local Permit. <br /> r']calendar Raffle [] Sports Pool [] Poker * [] Twenty-one * <br /> <br />[] Paddlewheels * <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br /> Game Type Description of Prize Retail Value of <br /> Prize <br /> <br /> Retail Value of <br />Game Type Description of Pdze <br /> Prize <br /> <br /> (Limit $12,000 per year) <br />Total: $ <br /> <br />Intended uses of gaming proceeds: <br /> <br /> organization <br /> presently <br /> have <br /> a <br /> gaming <br /> license? <br /> Yes <br /> - If "Yes,' the olganizafion is not eligible for a local permit or c~ari~ local <br />permit and should call the Office of Attorney General at 1-800-326-9240. <br /> <br />Has the organization received a charity local permit from this or another dry or county for the risc <br />the organization does not qualify for a local permit or chadty local permit. <br /> <br />Has Re organization received a local pen'nit from this or another city or county for the fiscal year <br />indicate the total value of all prizes previously awarded: $ . This amount is part of <br /> <br />[Si atu~ G[~t~on'~ 'ropf~cutive Official <br /> <br />21 year July I through June 30? 1~ No [] Yes - If "Yes," <br /> <br />July I through June 30? ~No []Yes - If"Yes," <br />he total pMze limit of $12,000 per year. <br /> <br />Business Phone Number <br /> <br /> <br />