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<br />er'it\ <br /> <br />"",",:s&:i;t "'"'' <br /> <br />'~1~1t'Q~7J" <br /> <br />&1JJmi+ i IV. 00 ajfpl,"Ca:}-Jon fa- <br />f~t1b Ji..(D WSll> Ut111J Ru& 101 <br />APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT vV;}}1 t)Jf'(hf) loteJ. <br />OFFICE OF A TIORNEY GENERAL YJml'I'"J. ',0, <br />SFN 9338 (10-2007) -~H ) v.vl JUT <br />Application for: ~Local Permit "" D Charity Local Permit (one event per year) <br />Date(s) of Activity <br /> <br />Name of Non-profit Organization <br /> <br />C J {? C C/ t~ 11/17 tv ,'lO'-~re C'- utf <br />Person Responsible for the Gaming Operation, Including Disbursement of Net Income <br />Lv RA/11 Ie. 5: 'Tfj;,f ,v~~ <br />Business Address City <br /> <br />~- )~C7 Y to 1-.2 C,- 2. ,~, C- <br />Title Business Phone Number <br />1i~J:! c#".,~~ v :l'f1~ o/"l16 <br />State Zip Code <br /> <br />Name of Site Where Game(s) will be Conducted <br />Ie; <br />City <br />U/If{r <br /> <br /> <br />p,,-/ II (;te~t..;4"/.? $" <br /> <br />'~ <br />County <br />C #~> <br />. Poker, Twenty-one, and Paddlewheels may be Conducted only by a Charily Local Permit. <br />DCalendar Raffle 0 Sports Pool 0 Poker' D Twenty-one' <br /> <br />City <br />CI5'fR/...~ - <br />Site Address <br />/2v/ <br />Zip Code <br />'f,;1QC <br /> <br />State <br />IV~ <br /> <br />Zip Code <br />S-t!&J I ~ <br /> <br />Mailing Address (if different) <br />jJt' #0 i- 3 t. <br /> <br />~~ <br />Check the Game(s) to be Conducted: <br />D Bingo NRaffle <br /> <br />State <br />tvlJ <br /> <br /> <br /> <br />o Paddlewheels' <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br />Game Type Description of Prize Retail Value of <br />Prize <br />)~.E ,?- i'l1"c Ih ~J) 5//- .E$ r- <br /> <br />Game Type Description of Prize Retail Value of <br />Prize <br /> (Limit $12.000 per year) <br /> Total: $~ ('}~,8~ <br /> <br />Intended uses of gaming proceeds: {,vt't.JPL,F# P.vIlA,Y~Ii~"frr: y"",..r#- ,.v"L"~"'i,"" ,.,.,{) Yv..-.1"N C ;t,.,p~ <br />, . <br /> <br />Does the organization presently have a state gaming license? IS(( 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? M No 0 Yes - If "Yes," <br />the prganization 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 .Yes," <br />indicate the total value of all prizes previously awarded: $ ;Z '!,P. ~ This amount is part of the total prize limit of $12,000 per year. <br />/ <br /> <br /> <br />Date <br /> <br />~- '1- CJ 8' <br /> <br />Title A'".Fr'-"I' 1'A';,~;o/ <br />g.'.IRtJ /J1,'f""" <br /> <br /> <br />Business Phone Number <br />:1~,?- '1?/~ <br />