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<br />51.t~lI\it ",0- GO Clfl'ljli1t~ -fet, = <br /> <br />APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT~ '1If!!U 0 J" .J-' <br />OFFICE OF ATTORNEY GENERAL Wlrn l.othpJde' {}.rP ICOJ It <br />SFN 9338 (07-2003) --11' L/uf <br />Application for: EJ Local Permit * 0 Charity Local Permit (one event per year) <br />l <br /> <br />Na~; of Non:profit PJ~anizatism .'" (. I ' <br />::;. [,yt.{ h. ./1;, " -I r ( /;.(, r y ( 4..-,/ <br /> <br /> <br />Date(s) of Activity <br />F~c h ). { Jt1to <br /> <br />~eh. d~ 1~:)j;U' <br /> <br />Person Responsible for the Gaming Operation, Including Disbursement of Net Income <br />si,,\!', 411tJ/7-<tS5 <br />Busi ss Address <br />0, ' (J' () Z 2 <br />Mailing Address (if different) <br /> <br />1 <br />,/e <br />County <br />C;:rs <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 />Name..9f Site Where Game(s) will ;e Conducted <br />::;:>c}l/cl/;./I . t rc Ii 0 { <br />City tV.t! <; y- r:~ ('C, tJ <br /> <br />'1 <br />~('l <br /> <br /> <br />Check the Game(s) to be Conducted: <br />o Bingo ~ 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 />/1 <br />& C ;;')1 l <br /> <br />i 7<::.' <br />/ ., <br /> <br />$ <br />s( <br /> <br /> <br />,,' <br />~ I AS <br /> <br />r. ' <br />'1 I ~1 () <br /> <br />Title <br />!3lJC{(i!.'( .41~ Pi i. <br />City,....- <br />~" r .' t/ <br /> <br />Business Phone Number <br />7dl- ;2 5<} ~"'e;"t.; <br />State Zip Code <br />/lJ/j SJ/ Ci <br />State lip Code <br /> <br />City <br /> <br />Site Address <br />'/(.J() / <br />Slate <br />tvO <br /> <br /> <br />)~l,/ Jl- <br /> <br />Zip Code <br />~>y(,)7 ?' <br /> <br />o Paddlewheels' <br /> <br />Game Type Description of Prize Retail Value of <br />Prize <br /> $ <br />I <br /> <br />I <br />I (Limit. $12,OOO~per year) <br />Total: ,$ U' / S ,()i) <br /> <br />Intended uses of gaming proceeds: <br /> <br />Does the organization presently have a slate gaming license? [tJNo 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 o:ga~ization received.a charity local perf!lit from J:!1is or another city or county for the fiscal year July 1 through June 3D? Qsl No 0 Yes. If "Yes: <br />the orgamzation does not qualify for a local permit or chanty local permit <br /> <br />~a~ the organization received ~ local p~rmit from this or another"city orcoun~ for the fiscal year July 1 through June 3D? ONo J:gJyes _ If"Yes,. <br />mdlcate the tolal value of all pnzes previously awarded: S 100. uO . ThiS amount is part of the total prize limit of $12,000 per year, <br /> <br />Executive Official <br /> <br /> <br /> <br />1-7 t#~( <br /> <br /> <br />'--=.--~-~-'--,"""'._----~--.-'__;r r <br />