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<br />~u~m) t (10.00 a{}f)l ct/-;orl ~~ <br />rO-ytWlt4n Wf()unJ:u aud,t <br />APPLICATION FORA LOCAL PERMIT OR CHARITY LOCAL PERMIT wi+n CoY)tr)tk~ apf),c2rtJ <br />OFFICE OF ATTORNEY GENERAL <br />SFN 9338 (07-2003) <br /> <br />Application for: <br /> <br />Name)f on-profit Or. Ja'Yfation L. <br /> <br />.J(L (;I t.-t.. <br />Person Responrible foZr the Gaming Operation, Including Disbursement of Net Income <br />I\.. __ r 1< C-I/ 0 ~ <br /> <br />B;Siness Address y ~ "e/ ~.J' E City <br /> <br />Mailing Address (if different) L-J J.... oCl.. 4...T /~ .. City I <br />L-' {-e..~-I k..... <br /> <br />I / Site Address <br />7' J,., "'- <br /> <br /> <br />*"'-i\~ <br /> <br />o Local Permit <br /> <br /> <br />Name of Sit? Where Game(s) will be Conducted <br />E""'bj~M /. I": ~ tl <br />City <br />E "1 t~ <br /> <br /> <br />* 0 Charity Local Permit <br />Date(s) of Activity <br />it - d.~~ d-OO'1 <br /> <br />(one event per year) <br /> <br />to \\- ~"doD1 <br /> <br />Title <br /> <br />Business Phone Number <br /> <br />;:;, 3 3'-;].;;z./ <br />State Zip Code <br /> <br />State <br />1'\,1>..J <br /> <br />Zip Code <br />>-L!5fJ7 <br /> <br />Co nty <br />~ ..r ..> <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 /> <br />f) t>~k <br /> <br />Check the Game(s) to be Conducted: <br />o Bingo ~e <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br />Game Type Description of Prize Retail Value of <br />Prize <br />~ fIle (~sL. ~ 00 <br />/>"C, <br />'" <br /> ID C- , c () <br /> ~o tJ C) <br /> <br />o Paddlewheels' <br /> <br />Game Type Description of Prize Retail Value of <br />Prize <br /> Total: t1~~~~oo <br /> , <br /> <br />Intended uses of gaming proceeds: <br /> <br />00 ~'- eL Y, 0 '- [ <br /> <br />7--c <br /> <br />!l-R~7 <br /> <br />Does the organization presently have a state gaming license? 0 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? 0 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 local permit from this or another city or county for the fiscal year July 1 through June 3D? 0 No 0 Yes - If "Yes," <br />indicate the total value of all prizes previously awarded: $ . This amountis part of the total prize limit of $12,000 per year. <br /> <br /> <br />(5J s:: 0 <br /> <br />zation's Top Executive Official <br />~- <br /> <br /> <br />Title <br />V;c.- (Jf~ ;,. &'" j ./;.....,., c <br /> <br />