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<br />~'LL~m;j- ~ 10,00 . ^ , - 'iol1.f1-ee, <br />r(;tya,~ l€, +0 (till ~LtntLj Uwl'+ <br />APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT \'\1 i-l-l1 Co mf letiiA dpfJiUtt <br />OFFICE OF ATTORNEY GENERAL <br />SFN 9338 (07-2003) <br />Application for. <br /> <br /> <br />o Local Permil <br /> <br />*,MCharity Local Permit (one event per year) <br />Dale(s) of Activity <br />tI\ "';1 <br /> <br />Name of Non-profil Organization <br /> <br />~- <br /> <br />~- <br />to l'ipr~ I ,~ <br />Business Phone Number I <br />101- 1/- :ll D <br />Slate Zip Code I <br />I\l D S''63l9,'''' <br />Zip Code I <br />s-<63 <J"" <br /> <br />I <br />I <br />I <br />o Paddlowheels . <br />I <br />I <br /> <br /> <br />L~ -1'\'\' VOlq ~'''' h',tt <br />r the Gaming Operation, IncludIng Disbursement of Net Income <br />eV' <br /> <br />nile <br /> <br />Business Address <br /> <br />Clly <br />Ral\o-. <br />City <br />Roll" <br />Silo Address <br />1....\ :l.. VV\ G< ~ V\ .Av < . <br />State Zip Code County <br />III D Lf7 Ca ~ \ <br />. Poker, Twenty.one, and Paddlewheels may be Conducted only by B Chanty local Permit. <br />DCalendarRaffle o Sports Pool OifPOker. 0 Twenty-one" <br /> <br />1'Ji>J <br /> <br />;;J. i "'--t .s~ <br />Mailing Address (If different) <br />?,O,8>o a'So <br />Name of Site Where Game(s) wtll be Conducted <br />, 1'v bOc.l(-(v !-'iV'OV <br /> <br />State <br />N:D <br /> <br />LCCIJ.,tY' <br /> <br />Clly <br /> <br /> <br />t'C 0 <br />Check the Game(B) 10 be Conducted: <br />o Bingo 0 Ramo <br /> <br />DESCRiPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br />Game Type <br /> <br />Retail Value of <br />Prize <br /> <br />Description of Prize <br /> <br />Retail Value of <br />Prizb <br /> <br />I <br /> <br />DescripHon of Prize <br /> <br />Game Type <br /> <br /> <br />~30.f <br /> <br />... <br /> <br />70 1'0 <br /> <br />:> < <br /> <br />.1"00\ <br /> <br />T <br /> <br />s d <br /> <br />Pi; <br /> <br />)',i< p ",J,d<d...1",~kd <br />.f'~-e"'- ""', ,-I co"", 1<->;0. <br /> <br />(4 <br /> <br />(LI....l$12COQpi!ryeafi <br />Totai: $ I 000 <br />I <br /> <br />I <br /> <br />I <br /> <br /> <br />Does the organization presenrty have 8 atalegaming license? giNo 0 Vea - If "Yes," the organization is not engibte for a local pennit or chariJlocal <br />pennit and ahoukl catl the Office of Anomey General at 1-80o.m-9240. <br /> <br />Has the organizatIon received a chartty local permit from this or another dty or county for the fiscal year July 1 through June 30? )wfNo 0 Yes- If "Yes," <br />the organlzsllon does not qualify for 8 local pennlt or charity local pennlt. ytaI <br /> <br />Intended us. of gaming procoedl: <br /> <br />Dovv-cl"O''-' -1"0 l<-e\w::l'Fo>f <br /> <br />L,-f" <br /> <br />Has the organlzaUon received a local permit from this or another city or county for the fiscal year Juty 1 through June 301 Jm No 0 Yes _ If 'rY'IOS . <br />Indicate the lotal value of all prizes previously awarded: $ . ThIs amount Is part of the total prize nmft of $12,000 per year. ' <br /> <br /> <br />I <br />Business Phone Number <br />70/-"/"3/ <br /> <br /> <br />IveOfficial <br /> <br />Date <br /> <br />Tille <br />UP /0<'-0.., <br /> <br /><..LA' <br /> <br />:s 10-Ocr <br /> <br />err <br /> <br /> <br />xl7 <br />