Laserfiche WebLink
<br /> <br />APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT <br />OFFICE OF ATTORNEY GENERAL <br />SFN 9338 (07-2003) <br /> <br />Application for: <br /> <br />~ Local Permit <br /> <br />* 0 Charity Local Permit (one event per year) <br />. Date(s) of Activity <br /> <br />Name of Non-profit Organization <br /> <br />aLE- Dee/!!.. ~t)tI).JD4-n()JJ <br /> <br />Person Responsible for the Gaming Operation, Including Disbursement of Net Income <br /> <br />cJ AU <br /> <br /> <br />N. <br /> <br />Name of Site Where Game(s) will be Conducted <br />11f{)471~6 ~ <br />City -fIo/14e'E <br /> <br /> <br />IJ.)C. <br /> <br />NfJV. <br />Title <br />CI1A1~ <br /> <br />to AlOV I :2tJ() <br />Business Phone Number <br />701..2.JlI-SVs-y. <br /> <br />NP <br /> <br /> <br /> <br />Zip ..,.9ode <br /> <br />State <br /> <br /> <br />Sit:i;~3s /, 7 tJ, Ate <br />State Zip Code <br />A.l~ SlaY7 <br /> <br />V <br /> <br />County <br />e,4~S <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 !jJ'Raffle DCalendar Raffle D Sports Pool D Poker' 0 Twenty-one' <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 />RA-~E <br /> <br />$ \~Q <br />~CO <br /> <br /> <br />o Paddlewheels' <br /> <br />Game Type Description of Prize Retail Value of <br /> Prize <br /> $ <br /> (Limit $12,000 per year) <br /> Total: $ a'1~ <br /> <br />Intended uses of gaming proceeds: S~rc)\+~"'~ .~ Mv...~ '\:::)e~(' b",!a*,~ C"",A '\-\-(, p-ullTJlV\.s' bY10CI~j <br /> <br />(V\u.Ck c\te r Jo-J, ~\().t\l-~i\ JOl" r o.~ ~\~ \-.abik-\- . <br /> <br />Does the organization presently have a state gaming license? III No DYes - 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? !if No DYes - If "Yes," <br />the organization does not qualify for a local permit or charity local permit. <br /> <br />Has the organization received a tocal permit from this or another city or county for the fiscal year July 1 through June 30? IBfNo DYes - If "Yes," <br />indicate the total value of all prizes previously awarded: $ , This amount is part of the total prize limit of $12,000 per year. <br /> <br /> <br /> <br />Title <br />Co ~~I~ <br /> <br />