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<br /> <br />5/.{btl\it flO- 00 (J{fliatttlT1 frt, = <br />APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT~lJ~ /oj.. <br />OFFICE OF ATTORNEY GENERAL tAl/Tn CDlltpWi! 6.PP/Ico.:flb' <br />SFN 9338 (07-2003) ,~ ~ () it <br />./ <br />Application for: IJLocal Permit ., 0 Charity Local Permit (one event per year) <br />Date(s) of Activity <br />(It..t1 lit} 1 7 <br />tion, Including Disbursement of Net Income <br /> <br /> <br /> <br />1ell- <br />State <br /> <br /> <br />City <br /> <br /> <br />~ <br />J--ti Ii ~ (. <br /> <br />Check the Game(s) to be onducted: <br /> <br />o Bingo ~ Raffle <br /> <br />Ci~ <br /> <br />rf ("i <br />Site Address <br />"7 l .0' <br />() (,' ( <br />State <br />tI/J <br /> <br />Zip Code <br />~J-'> ( <; <br />., ,r <br /> <br /> <br />State <br />'# <br />,4..e.- <br />Countv <br />C4'J ;; <br /> <br />~ Poker, Twenty-one, and Paddlewheels may be Conducted only by a Charity LoCal Permit. <br />o Calendar Raffle 0 Sports Pool 0 Poker ~ 0 Twenty-one ~ <br /> <br />o Paddlewheels' <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br />Retail Value of <br />Prize <br /> <br />tl{) <br /> <br />Game Type Description of Prize Retail Value of <br /> Prize <br />I $ <br /> -- <br />I <br />I <br />I <br /> (Umit $12,000 per year) <br /> Total: $ "7 (j,') <br /> <br />Game Type <br /> <br />Description of Prize <br /> <br /> <br /> <br />$ <br /> <br />..- ,1""" /'" : <br />I ') v <br /> <br />/)"U <br /> <br />Intended uses of gaming proceeds: .~-".-l{ a;~ :d1 ~~i ,/-;1;"1/ <br /> <br />Does the organization presently have a state gaming license? [~ No 0 Yes - 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? 1&1 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 permit from this or another city or county for the fiscal year July 1 through June 30? 51' 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, OObper year. <br /> <br /> <br />Executive Official <br /> <br /> <br />~.~/ <br /> <br /> <br />- <br />