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<br /> <br />'" 5I.\b",;t flQ. aD ~i Citb'tJrl-# = <br />APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT~c,~ ".L' <br />OFFICE OF ATTORNEY GENERAL WJrn CDJhpJditJ ~fPIlC~ It <br />SFN 9338 (07-2003) <br /> <br />Application for: <br /> <br />o Local Permit <br /> <br /> <br />* 0 Charity Local Permit (one event per year) <br />Date(s) of Activity :3- 6 _ (1"'. ) 6. ;; " (\. I <br />~,-4fij- to <br />Title <br /> <br />21; 'J!5. SC/-!t:> ~ /912 <br />Person Responsible for the Gaming Operation, Including Disbursement of Net Income <br /> <br /> <br /> <br />e> <br />Business Address ~ <br />Ale> IV' t:..' <br />Mailing Address (if different) <br /> <br /> <br />Name of Site Where Game(s) will be Conducted <br />J..1hL <br /> <br />City hf I I <br /> <br /> <br />City <br /> <br />Business Phone Number <br />?o/- 79,. 151.7 <br />Zip Code <br /> <br />State <br /> <br />CitY, / <br />.// I <br />....1 IV <br /> <br />Site Address <br />/' <br />eN; <br /> <br />Sf\j <br /> <br />e'~'. . <br /> <br />Sta'n <br />NV <br /> <br />Zip Code <br />5id.5 j. () I q <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 />o Bingo ~ Raffle o Calendar Raffle 0 Sports Pool 0 Poker * 0 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 />iZFFle mONEY $ . . <br />{ODe> <br /> I <br /> I <br /> I <br /> I <br /> <br />o Paddlewheels' <br /> <br />Game Type Description of Prize Retail Value of <br />Prize <br /> I $ <br /> I <br /> , <br />I <br /> (Limit $12.000 per year) <br /> Total: $ \ D(x .'; rfi <br /> <br />Inte:Jded uses of gaming proceeds: <br />:> c.1-/ c:o L- <br /> <br />CIV~ <br />.5 t; IJ /6> ,2.. S <br /> <br />5L/I/p L..44-S/~/ P5 <br /> <br />To <br /> <br />H 101-J <br /> <br />Does the organization presently have a state gaming license?"EJ 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? ~ No 0 Yes - If'Y es," <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? ygj No 0 Yes - If "Yes," <br />indicate the total value of all prizes previously awarded: S . ihis amount is part of the total prize limit of $12,000 per year. <br /> <br /> <br />Dai / <br />/ 8'{C> 7 <br /> <br />S' a reofO an~ <br /> <br /> <br />I~ <br /> <br />