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<br />~ &lJJ(1J)f ~lo.OOajp)tMlon 1e6 <br />~~t1bJ~..(o WSt:oLU1-hj ttu&1o( <br />PERMIT OR CHARITY LOCXL PERMIT W;}}l CGf\1~ kteJ .. <br />~ I,. ('a-h t9f, <br /> <br />.~ <br /> <br />APPLICATION FOR A LOCAL <br />OFFICE OF ATTORNEY GENERAL <br />SFN 9338 (10-2007) <br /> <br />Application for: <br /> <br />o Local Permit <br /> <br />Name of Non-profit Organization <br />;-e; I /) 'e.. <br /> <br />C/u/:; <br /> <br />1(11) lie) 'fa <br />Person Responsible for the Gaming Operation, Including Disbursement of Net Income <br />L, L BcrtJ'G- <br /> <br />Business Address <br /> <br />JCJ~I CJ 3' ST <br />Mailing Address (if different) <br /> <br />a..- <br /> <br />S~tr)~ <br />Name of Site Where Game(s) will be Conducted <br />WeSt r~v9t::1 r~ /v GveJt..Jr?~S <br /> <br />City <br /> <br />We.e>i <br /> <br />- <br />/"';;>r1 d <br /> <br />* 0 Charity Local Permit (one event per year) <br /> <br />Date(s) of Activity <br />J-f./ <br />Title <br />yye~5 , <br /> <br />City J' <br />\1.0 Ie <br />City <br /> <br />to Y --w /Of <br /> <br /> <br />Business Phone Number <br />76/- Rfo - 92,50 <br />State Zip Code <br />/tI 0 o7~ <br />State Zip Code <br /> <br /> <br />Site Address <br />-9a,'y GVClut1dS <br />Zip Code County <br />S-B-It!) ~ CaS5 <br /> <br />State <br />/110 <br /> <br />Check the Game(s) to be Conducted: . Poker, twenty-one, and Paddlewheels may be Conducted only by a Charity Local Permit. <br />o Bingo E8:I Raffle DCalendar Raffle 0 Sports Pool 0 Poker' 0 Twenty-one' <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br />Game Type Description of Prize Retail Value of <br />Prize <br />Pa.q/ e \taJAjpc.YJol" .p 1.000 - <br /> <br />o Paddlewheels' <br /> <br />Game Type Description of Prize Retail Value of <br /> Prize <br /> (Limit $12,000 per year) <br /> Total: $ 6l.~.OO <br /> <br />Intended uses of gaming proceeds: He/ fJ COiJ Gv' eo,s T of f:riT c,m u../ <br /> <br />Does the organization presently have a state gaming Iicense?.--M 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? reNo 0 Yes - 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 30? Ilrf No 0 Yes - 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 />ue~ <br /> <br /> <br />R) - 8:'f/cJ - ~R5eJ <br />