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<br />i(~) <br /> <br /> <br />, ~7::~~._.-- <br /> <br />&iJJ(lJJf i 10.00 awH'act,.on fa" <br />fCU3C1b Ji 11> Cats t't> un 1y ftu& ivy <br />APPLICATION FORA LOCAL PERMIT OR CHARITY LOCAL PERMIT wi}}1 Cof\1rJlet~ <br />OFFICE OF ATTORNEY GENERAL I()AJJIlf~J;&n <br />SFN 9338 (10-2007) -~f( <br />Application for: 18: Local Permit * D Charity Local Permit (one event per year) <br /> <br />c <br /> <br />Date(s) of Activity <br /> <br />I - dW- dDC8 <br />Title <br />flPrt# c <br /> <br />to 1- ~0 - d-O <br /> <br />Name of Non-profit Organization <br /> <br /> <br /> <br />Business Phone Number <br /> <br />3 C; '}-'7' '1/6 <br />State Zip Code <br /> <br />City <br /> <br />Mailing Address (if different) <br /> <br />10 #/x 5J~ <br />Name of Site Where Game(s) will be Conducted <br />,//, ~ iI-/fi c;a,.t- ,-vP <br /> <br />City <br />C J-{!, t.- <br />Site Address <br />1.1 C' / h/;F',r <br />State Zip Code <br />J/I} S-~, 9~ <br /> <br />State <br /> <br />jVlJ <br /> <br />Zip Code <br />S- ff .,/;2 <br /> <br /> <br />(,,0 <br />Check the Game(s) to be Conducted: <br />o Bingo I2Q Raffle <br /> <br />,/11~.- Ir 1"/2 <br />County <br />C1-S'f" <br /> <br />* Poker, Twenty-one. and Paddlewheels may be Conducted only by a Charity Local Permit. <br />DCalendar Raffle 0 Sports Pool 0 Poker * D Twenty-one' <br /> <br />o Paddlewheels * <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br />Game Type Description of Prize Retail Value of <br /> Prize <br />I?#-Frl.-F ,# . <br />C if II l .I~# <br />}? ir~t-/i C ~>' /T *'; ~~U) <br /> <br />Game Type Description of Prize Retail Value of <br />Prize <br /> (Limit $12,000 per year) <br /> Total: $ :z .;? c? 0.00 <br /> <br />.,/ ~P't:?. eo>.!> <br /> <br />Intended uses of gaming proceeds: w/l-nL"):L Iiv/7lA.v,cH..YlA ..,,7 !+,v t1 <br /> <br />y..... 7/1 <br />/ <br /> <br />I,/}h-C-dr-,b""- d..-v'.IJ y"J.# 7; C "A,Af <br />I' <br /> <br />Does the organization presently have a state gaming license? f><f No 0 Yes - If "Ves," 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~es - If "Ves," <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 30? 0 No ~ Yes - If "Ves," <br />indicate the total value of all prizes previously awarded: $ ~ <.!J t5 . This amount is pan of the total prize limit of $12,000 per year. <br /> <br /> <br />~ <br /> <br />Date <br />11-6- 0 I) <br /> <br /> <br />Business Phone Number <br /> <br />7"'?.-~?/G, <br />