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<br />5" v.bmjt flo. 00 O{fIi CI1-tbrl{tL- = <br /> <br />APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT~IJ~,. ..1. <br />OFFICE OF ATTORNEY GENERAL Wlrn ~o~~i~ Afp11C04Ii' <br />SFN 9338 (07-2003) 11 .., d ~ <br />Application for: ~ Local Permit .. 0 Charity Local Permit (one event per year) <br />Date(s) of Activity <br />11/~ <br />Title <br /> <br />Na~ 0) Non-pro jt 9'ganization, / <br />L: tLa:.. fL~ L I 0 YL 9 <br />Person Responsible for the Gaming Operation, Induding Disbursement of Net Income <br />R<IC.. Y" /( 1 ~ 1/ ~ <br /> <br />Business Address City <br /> <br /> <br /> <br />Mailing Address (if different) <br />IV'S- <br /> <br />r <br /> <br />Name of Site Where Ga~~) will be Conducted <br />F f"1 /;, J~"t ,Pa...r....... (~ /..{."'1.. j ~ ""'- <br /> <br />City t;~m V n <br /> <br />. J-/ <br />oS Clc... / r <br /> <br /> <br />f(J <br />O,t: d - J7..}tt1 <br /> <br />Business Phone Number <br />r::l.3 J' ~J::l /, <br />Zip Code <br /> <br />State <br /> <br />CiUoll.J~hJ <br />Site m'F <br /> <br />Stat~1\ Zip COQe, <br />NlJ ~) ~17 t-l <br /> <br />State <br />Yl , p" <br /> <br />Zip Code <br />S't:f'o? <br /> <br /> <br />Check the Game(s) to be Conducted: .. Poker, Twenty-one, and Paddlewheels may be Conducted only by a Charity LoCal Permit <br />D Bingo ~ DCalendar Raffle 0 Sports Pool 0 Poker" D Twenty-one .. <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br />Game Type Description of Prize Retail Value of <br />Prize <br />llallk PC-5~ ~/~, oc> <br /> ~.Io 1>, OC <br /> .. ", <br /> ro, otP <br /> <br />o Paddlewheels' <br /> <br />Game Type Description of Prize Retail Value of <br />Prize <br /> $ <br /> (Limit $12,000 per year) <br /> Total: $ s.ct:J .~ <br /> <br />Intended uses of gaming proceeds: <br /> <br />De>...............f: .".... <br /> <br />7'-... <br /> <br />^~o4t7 <br /> <br />Does the organization presently have a state gaming license? D 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 3D? D 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 0 Yes - 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 />Top Executive Official <br /> <br /> <br />Date <br />(pe.f /~. o~ <br /> <br />Title <br />V:cte. <br /> <br /> <br />Business Phone Number <br />Jz.31' - 3 2./?," <br /> <br />-- <br />