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<br /> <br />5u.!tJlt\if -110- 00 appliCltlf/J'f1 fee,= <br />/;,;~\ APPLICATION FORA LOCAL PERMIT OR CHARITY LOCAL PERMIT~CJIlf!!IA )"'.1.' <br />~\~l, OFFICE OF A TIORNEY GENERAL w'rn cprr.p.ld-e~ ~pp I co.l" <br />" ,,~. SFN 9338 (07-2003) <br />t'OI"...o..~o <br />Application for: 0 Local Pennit . (one event per year) <br /> <br /> <br />Title <br /> <br />Business Phone Number <br />'0' 2.o'lS' ~ <br />Slate Zip Code <br />I\l D '5~ 10 <br />Slate Zip Code <br /> <br />Name of Non-profit Organization <br />I <br /> <br /> <br />City <br /> <br />City <br /> <br /> <br />Name 01 Sfte Where Game(s) will be Conducted <br /> <br />Site Address <br /> <br /> <br /> <br /> <br />Check the Game(s) to be Conducted: <br />D Bingo D Raffle <br /> <br />, Poker, Twenty-one. and Paddlewheels may be Conducted only by a Charity Local Permit <br />DCalendar Raffle D Sports Pool ~oker' D Twenty-one' <br /> <br />D Paddlewheels' <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br />Retail Value of <br />P' <br /> <br />Game Type <br /> <br />Description of Prize <br /> <br />Game Type <br /> <br />Description of Prize <br /> <br />Retail Value of <br />Prize <br /> <br />o <br /> <br /> <br />$ <br /> <br />Total: <br />. ..,.< 00 tlO~ <br /> <br />IntendedusesolgamingprOceeds:~ealthca.re ~e..f.d.~ fOr Cl.yl-e. Peters-on <br /> <br /> <br />Does the organization presently have a state gaming license? MNo 0 Yes . If "Yes,. the organization is not eligible for a local permit or charity local <br />permit and should call the Office 01 Attomey General at 1-800-326-9240. <br /> <br />Has the-organization received a charity local permit from this or another city or cour'lty for the fiscal year July 1 through June 307 ~o 0 Yes - If "Yes," <br />,the Qrganlzauon does not qualify for a local permit or charity loca\ permIt <br /> <br />Has the organization received a local permit from this or another city or county for the fiS~l year July 1 through June 3D? ~o Dyes - 11 "Yes," <br />indicate the total value of all priZes previously awarded: $ . This amount is part of the total prize lima of $12,000 per year. <br /> <br /> <br />