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OFFICE OF ATTORNEY GENERAL <br />SFN 9338 (07-2003) <br /> <br /> Application for: l'~-Tkocal Permit * [] Charity Local Permit (one event peryear) <br /> <br />Name of Non-profit Organ~tion <br /> <br />~e~0n R~ponsible for ~e Gaming Open,on, Including Disbu~ement of Net In.me <br /> <br />Business Address City <br />Mailing Address (if different) <br />Name of Site Where Game(s) will De Conducted <br />C~ty <br /> <br />Date(s) of Ac~vity <br /> /-3 / - ~ ?' to <br />'~,,-/,'" '~-~/"-~ ~ I ausiness Phone. Number <br /> IState I Zip Code <br /> State I Zip Code <br /> <br />Site Address <br /> <br />State J Zip Code <br />r~ , p,J-I <br /> <br />JCoun~.,.,~ <br /> '..- "~,.- ..5_5 <br /> <br />Check the Game(s) to be Conducted: * Poker, Twenty-one, and Paddlewheeis may be Conducted only by a Charity LoCal Permit. <br /> [~q~go [~]..Ra~e []Calendar Raffle [] Sports Pool [] Poker' [] Twenty-one * <br /> <br />[] Paddlewhests' <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br />Game Type Description of Pdze Retail Value of <br /> Prize <br /> ,. p/,.,.,5 , <br /> <br />Game Typ~ Description of Pdze Retail Value of <br /> Prize <br /> $ <br /> <br /> I (Limit $12,000 per year) <br /> Total: $ <br /> <br />Intended uses of gaming proceeds: <br /> <br />Does the organization presently have a state gaming license? [~0 [] Yes - If "Yes,' the organization is not eligible for a local permit or charity kx:al <br />permit and should call the Office of Attorney General at 1-800-326-9240. <br /> <br />Has ~e organization received a chadty local permit from this or another city or county for the fiscal year July I through June 30? [~-No [] Yes - If Wes," <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 I through June 30? ~lb [] Yes - If "Yes," <br />indicate the total value of all prizes previously awarded: $ . This amount is part of the total ptfza limit of $12,000 per year. <br /> <br />JSignature of Oftjanizatio~'s Top Executive Official <br /> <br />jDate j Tiff Business Phone Number <br />1.2-/~- - o L; ]/,'~ ?~.~, ~73,~ - .3&) ~ <br /> <br /> <br />