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<br /> <br />5" v.bll\it flo. 00 ~iCl1-tbrl-itL = <br />APPLICATION FORA LOCAL PERMIT OR CHARITY LOCAL PERMIT~IJ~ j'__.L' <br />OFFICE OF ATTORNEY GENERAL /NUn cO"'Pwi! App 'co.:Ili' <br />SFN 9338 (07-2003) *\-1&';' <br /> <br />Application for: <br /> <br />~ Local Pennit <br /> <br />Name of Non-profit Organization } /} <br />(JOY ~r Wi I j,'/~ <br />Perso~esponsib e for the 13aming Operation, Induding Disbursement of Net Income <br />t l '- t/ L.e V () <br />Business Address City <br /> <br />Zip Code <br />'-f'-li <br /> <br />.. Poker, Twenty-one, and Paddlewheels may be Conducted only by a Charity LoCal Permit <br /> <br />DCalendar Raffle 0 Sports Pool 0 Poker" 0 Twenty-one .. <br /> <br /> <br /> <br />Check the Game(s) to be Conducted: <br />o Bingo [B"Raffle <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 Prize <br /> <br /> <br /> <br />$ ~~~, <br />/0 t? _ <br /> <br />.. 0 Charity Local Permit (one event per year) <br />Date(s) of Activity <br />{J/ tV v. ;;; 7 -- ';?(!)s6 fv i J- :)(?-1JJO}j <br />Title <br /> <br /> <br /> <br /> <br />o Paddlewheels' <br /> <br />Game Type Description of Prize Retail Value of <br />Prize <br /> $ <br /> (~$12,OOO per year) <br /> Total: $ 41061... <br /> <br />Intended uses of gaming proceeds: <br /> <br />..t. ?/~"-.$(2 < /' ~ ~4- r<l. <br /> <br />~'t Ie,; 54-H <br />/ <br /> <br />Does the organization presently have a state gaming IicenSe?JZl.No Dyes - If "Yes," the organization is not eligible for a local permit or charity 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 city or county for the fiscal year July 1 through June 30? ~No DYes - If"Yes: <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? D No Dyes - If "Yes." <br />indicate the total value of all prizes previously awarded: $ . This amount is part of the total prize limit of $12, 000 per year. <br /> <br /> <br /> <br />Title <br />~-I ~~1., <br /> <br /> <br />~.,~ <br />