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<br />~Li~m)~ 110.00 c2Pfhctt;on +'-eR; <br />fO-~())o)t ~ Gill G>unJ:u ~l+~( <br />APPLICATION FORA LOCAL PERMIT OR CHARITY LOCAL PERMIT Wl-tn Comr)~fJ apf}IC2tf~ <br />OFFICE OF ATTORNEY GENERAL <br />SFN 9338 (07-2003) <br />Application for: <br /> <br /> <br />~ Local Permit <br /> <br />Name of Non-~rofit Organization <br />N Oy ().. L u. \h -e.<{ (!lA\ C h U..X ~ <br />Person Responsible for the Gaming Operation, Including Disbursement of Net Income <br />~ <br />bil i1 i'(.. ".lllL~ <br />Business Address <br />G(U', <br />Mailing Address (if different) ,.,.. <br />OVlCt.... ~J/ ~ StnJ- 17 t::)' I 1'5 5'r 5' E <br />Name o,.f 9ite Where Game(s] will be Conducted. J <br />IVetCL lk n k 4..'(C~ <br />City ; <br />C(M~V\~ <br /> <br />* D Charity Local Permit <br />Date(s) of Activity <br />{; C/t b Zoo '7 <br />TJ!le <br />Vres _\.vI fLeA <br />City G <br />~ a\fcln~w <br />Cit~ <br />G o--\.~ \'\. .e. Y <br /> <br />(one event per year) <br /> <br />to uet Lo 200-, <br />Business Phone Number <br />At~'-I' 55.55 <br /> <br />Site Address <br />1<..<<- <br />State Zip Code <br />N '5 ?o3 " <br /> <br /> <br />Zip Code I . <br />5 g--lI 3 l;7 <br /> <br />Zip Code, I <br />5 ~tl3co <br /> <br />co~~ <br /> <br />Check the Game(s) to be Conducted: . Poker, Twenty-one, and Paddlewheels may be Conducted only by a Charity Local Permit. <br />D Bingo )d'Raffle DCalendar Raffle D Sports Pool D Poker' D Twenty-one' <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br />Game Type <br /> <br />Description of Prize <br /> <br />Retail Value of <br />Prize <br /> <br />ry ~ to; <br />'75,f.l" <br />50 /~ ~ <br /> <br /> <br />It <br /> <br />1\ <br /> <br />D Paddlewheels' <br /> <br />Game Type Description of Prize Retail Value of <br />Prize <br /> (Limit $12,000 peryea~ <br /> Total: $ dOO. v.:; -e:ett <br /> , <br /> <br />Intended uses of gaming proceeds: <br /> <br />r :ilu- tvELCA- 7~ t ~ -i t--ku.-'rck PV'oJ'~c:i.5 <br /> <br />Does the organization presently have a state gaming license? 1'56 No DYes - If "Yes," the organization is not eligible for a local permit or charity local <br />permit and should call the Office of Attomey General at 1-800-[26-9240. <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? M No DYes - If "Yes," <br />the organization does not qualify for a local permit or charity local permit. ~ <br /> <br />~a~ the organization received a local p~rmit from this or another ci~er county for the fiscal year July 1 through June 30? D No ~ Yes - If "Yes," <br />indicate the total value of all prizes previously awarded: $ J lib, .... . This amount is part of the total prize limit of $12,000 per year. <br /> <br /> <br /> <br />f - ! i -0 7 <br /> <br /> <br />Business Phone Number <br />'-(?'( '553!i <br />