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<br />5" Ll.bl/lit flo. 00 rl{fIi C/Wbtl f&., = <br /> <br />APPLICATION FORA LOCAL PE'RMIT OR CHARITY LOCAL PERMIT~CJllf!A I'--J.' <br />OFFICE OF ATTORNEY GENERAL /Nlfn CDblpWi! AfP I~ ,'" <br />SFN 9338 (07-2003) if i{oq <br />Application for: I3J Local Permit * 0 Charity Local Permit (one event per year) <br />Date(s) of Activity <br />Id.-1O-0'1 <br /> <br /> <br />Name of Non-profit Organization <br />(:.li... ') ~ Co III V\., <br /> <br />Sou e..: <br /> <br />th S~ '< i. (0..{) <br />Person Responsible for the Gaming Operation, Including Disbursement of Net ncome <br /> <br />to IJ-IO-- 07 <br /> <br /> <br />l~ <br /> <br />w <br /> <br />\ ~ s-t <br /> <br />VV\cUY\ <br /> <br />Mailing Address (if different) <br />p6 601- II <br />Name of Site Where Game(s) will be Conducted <br />00 \"\.Gl V\ ~v\ I\..~ <br />City <br /> <br /> <br />Title <br />bOM.~ IfY\ <br />City <br />W esT ~A-tZ61 D <br />City <br /> <br />Business Phone Number <br /> <br /> <br />2-'"tl-7-l/2-Z- <br />State Zip Code <br />AJ D S--yO 7 &- <br />Zip Code <br />58'07~ <br /> <br />State <br />bST PJl-r2..61D N D <br />Site Address <br />I~SI W. VVlCL:l" <br />State Zip Code County <br />'D S"6 07 ~ c;. A-S & <br /> <br />Check the Game(s) to be Conducted: * Poker, Twenty-one, and Paddlewheels may be Conducted only by a Charity LoCal Permil <br />D Bingo Raffle 0 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 />V'6..-ft:t ~ OLAlLI $ 'lSo\~ <br /> <br />o Paddlewheels' <br /> <br />Game Type Description of Prize Retail Value of <br /> Prize <br /> $ <br /> (Umit $12,000 per year) <br /> Total: $ fC:;{)~ <br /> <br />Intended uses of gaming proceeds: (') ~'V o-.:;:t:; ~ .e~~. tf6 ~ -z...P--'-.ri. \ ~ <br /> <br />Does the organization presently have a state gaming license? M No 0 Ves . If "Yes," the organization is not eligible for a local permit or cl1arity local <br />permit and should call the Office of Attorney General at 1-800-~9240, . <br />2-00'7 ~ <br />Has the organization received a charity local permit from this or another city or county for the fiscal year July 1 ough June O? No Dves - If .Yes," <br />the organization does not qualify for a local permit or charity local permil <br /> <br />Has the organization received a local permit from this or another city or county for the fiscal year July 1 throu h ~n~~o. 0 No ~ves - If "Yes," <br />. 'cate the total value of all prizes previously awarded: $ '7 C; 0, tf1) , This amount is part of the total prize " 2,000 per year. <br /> <br /> <br /> <br />