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<br />5 Qb tl\it "10. 00 Cl{.fJi CltttJtl fee, jluJ~k <br />~.~"~t . - CoJ C,li~ IJ~ <br />l'Z.~J'~~. \ APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT 1.~1. U. .1'uJ.. <br />· (L "",,9 OFFICE OF ATTORNEY GENERAL WI n CDYfa(>J&le APP/I~ II <br />;~ '" 4.'-:.1: ,.'i SFN 9338 (07-2003) <br />~o'Jlo.~'O'" <br />Application for: 0 Local Permit " 0 Charity Local Permit (one event per year) <br />Date(s) of Activity <br /> <br />N;me{~ ;o~~:~fit ~,~gan:ti~nlc-( /: 4 YcJ l)L 4<:J ~q' c <br /> <br />Perso't, ~espo. nsi~e for the paming Operation, Including Disbursement of Net Income <br />1 (,..,.J (I L€- t/ c.$ <br />Business Address City <br /> <br /> <br />City '- . <br />f ;1 b?/ <br /> <br /> <br />~, " "' /# <br />to ref.?:7 ) <br />Business Phone Number <br /> <br />Title <br /> <br />State <br /> <br />Zip Code <br /> <br /> <br />Zip Code <br />!; y-t) 7,/ <br /> <br />~l <br /> <br />f~fq~ <br /> <br />Check the Game(s) to be Conducted: <br />[j;;}Brngo Ib1-Raffie <br /> <br />6' 5'?' <br />* Poker, Twenty-one, and Paddlewheels may be Conducted only by a Charity LoCal Permit <br />o Calendar Raffie D Sports Pool 0 Poker * 0 Twenty-one * 0 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 />.12/ ' Val IOU;' $ <br />/..:?; /1 '" C' . " f..< <br />/ ( <br />;-: ,--:2- e .; <br /> ~ ,?, <br /> (' .. L , <br />/;-./4 /7///lf/f./!lc .I' <br />'1 ? C ,. <br /> fi). 0}j{ .# J t:i"';, <br /> <br />Game Type Description of Prize Retail Value of <br /> Prize <br /> $ <br /> ! <br /> lmit $.12,000 per year) <br /> Total: ~(/O. <br /> , <br /> <br />IntendedUSeSOfgamingproceed~{j~, gJ OIl )~4) /l'.J(j~ fy> /~....q /"lj:; <br />~ L ' V <br />,~,,?zd;;./\ ~/"". e ",<-.-T5 1''''1 <br /> <br />Does the organization presently have a state gaming license? IEJNo 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? [B-N'o 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 permit from this or another city or county for the fiscal year July 1 through June 30? 0 No lE'Y~s - If "Yes," <br />indicate the total value of all prizes previously awarded: $ '-r t) C;; . This amount is part of the total prize limit of $12, 000 per year. <br /> <br />5 Top Executive Official <br /> <br /> <br />(. <br /> <br />Date <br />~-5r-c:.? <br /> <br />i'! _.-'-''II!Il F <br /> <br /> <br />,:/ . / . <br />/'c''"r.P<JJr <br /> <br />