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<br /> <br />~uvm; t t ~.(YJ .A .. - ')on-P-ei; <br />P&t~tW)t -tD Gill Durctu Uut\'+ <br />APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT wl-l-h Cofrtr1tkfJ dff}laff. <br />OFFICE OF ATTORNEY GENERAL <br />SFN 9338 (07-2003) <br />Application for: <br /> <br />o Local Pennit <br /> <br />it }( Charity Local Permit (one 8Y8flt per year) <br />Date(s) of AdMty . ;;2(P- ~_ <br />v:\ ~I ~ to ~pV'~ \ .~ <br />TItle Business Phone Number <br /> <br />w <br /> <br />Name of NOf11lrofil OrganlzlUon <br /> <br /> <br />CIty <br /> <br /> <br />City <br />Ro\ \C'A. <br />CIty <br />Ro\("" <br />Slle Address <br />Y :t r\r\ 0 ~ Y"\ Av <: . <br />Slate Zip Code County <br />tV D Lf7 Ga, \ <br />. Poker, Twenty-one, and Paddlewheels may be Conducted only by a Charity Local PermIt. <br />DCalendlr Raflle 0 Sports Pool .POker. 0 Twenty-one. <br /> <br />to/- <br />State <br />ND <br /> <br /> <br />;;;;l. I ~+ S.-f. t\.HJ <br />Milling Address (If dI1ferenl) <br />P,O. 8.0 a~o <br />Name of Site Where Game(s) wHI be Conduded <br />. -evbOc.\(:t'V' L..J litOv' <br /> <br />Slate <br />/Vi> <br /> <br />Loc.}l, e V' <br /> <br />I'C a", <br />Check the Game(s) 10 be Conduded: <br />o Bingo 0 Rime <br /> <br />o Paddlewheels * <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br />Game Type <br /> <br />Descriplion of Prize <br /> <br />Retail Value of <br />Prize <br /> <br />Game Type <br /> <br />Description of Prize <br /> <br />Retail Value of <br />Prize <br /> <br /> <br />Pool <br /> <br />I lIml S 12 000 per yea~ <br />Total: $ 0.00 <br /> <br />Intendecl u... of g.mIn, pl'OCHdl: <br /> <br />DoywdloV) --TO ge\~~ "'F'ov L.-f-e <br /> <br />Does the organlzlltlon presently haY8 a ltate gaming license? '&tNo 0 Yel - If *Yel," the organization Is not eRgible for a local pennit or charity local <br />pennit and lhould call the Office of Attorney General aI1-soo.6"6-92040. <br /> <br />Hal the organlzaUon rec:eIved I charily local permit from this or anolher c:IIy or county for !he fiscal year July 11hrough June 3O? )gf No 0 Yea. If *Yes." <br />the organization does not qualify for a local permit or charily local permit. "" <br /> <br />Has !he organlzlltlon received a local permit from thlll or anolher c:IIy or county for the fiscal year July 11hrough June 30? 1m No 0 Yea . If *Yes," <br />Indicala the lolal value of all prlzea previously swarded: $ . ThIs amount Is patt of the total prize Omit of S12.000 per )l8ar, <br /> <br /> <br />Title <br />UP / OW~~ <br /> <br /> <br />x 17 <br />