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<br /> <br />'. 5t.t~tn.it flO.OOappliCi11i~{ee,= <br />APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT~^ llf!!IA 0 )0__.L' <br />OFFICE OF ATTORNEY GENERAL wrrn ,oIllpJde~ o.fPI~lt <br />SFN 9338 (07-2003) <br /> <br />Application for: <br /> <br />Jiij Local Permit <br /> <br /> <br />Name of Non-profit Organi?2tion <br />~ <br /> <br /> <br />. D Charity Local Permit (one event per year) <br />Dale(s) of Activity <br />De: <br /> <br /> <br />Person Responsible for the Gaming Operation, lnduding Disbursement of Net Income <br />, ,- <br /> <br />BUSi~:3NUmber <br />Stale Zip Code <br /> <br />TWe <br /> <br />Business Address City <br /> <br />Check the Game(s) to be Conducted: <br />D Bingo ~ Raffle <br /> <br />e: <br /> <br />. Poker, Twenty-one, and Paddlewheels may be Conducted only by a Charity LoCal Pennit. <br />Dealendar Raffle 0 Sports Pool D Poker. 0 Twenty-one. <br /> <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br />Game Type <br /> <br />Retail Value of <br />Prize <br /> <br />Description of P . e <br /> <br /> <br />$ <br /> <br /> <br />o Paddlewl1eels. <br /> <br />Game Type Description of Prize Retail Value of <br /> Prize <br /> $ <br /> . <br /> (lJmit $12,000 per year) <br /> Total: $ <br /> <br />Intended uses of gaming proceeds: ~ q./f,,4A +./M ff~ '7.f- ~ ~.4d~~ <br /> <br />Does the organization presently have a state gaming license? ~No Dyes - If -Yes," the organization is not eligible for a local permit or charity local <br />pennit and should call tI1e Office of Attorney General at 1-800-32&-9240. <br /> <br />Has the organization received a charity local permit from this or another city or county for the fiscal year July 1 through June 30?;RJ No 0 Yes _ If 'Yes," <br />the organization does not qualify for a local permit or charity local permit <br /> <br />Has the organization received a local pennit from this or another city or county for the fiscal year July 1 through June 30? -jRfNo Dyes _ If"Yes," <br />indicate the total value of all prizes previously awarded: $ . This amount is part of the total prize limn of $12, OODPer year. <br /> <br />Business Phone Number <br /> <br /> <br />Date <br />27~' <br /> <br /> <br />- <br />