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<br />..l~~t'tr~\ . <br />:......'. t"~f(: ".' <br />,..~. ." <br />,~:_: .', d,':;:: <br />. ' . . .. <br />'. ::... . - ::_" <br />''f'.:; ..'.L "::>t. i~' <br /> <br />''>>;:.f.'.l':'":':''' '~~".''\~~~ <br />'l' :\<un'\', <br /> <br />APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT ,,~)..~ qe,. U 1-7S" <br />OFFICE OF ATTORNEY GENERAL r- <br />SFN 9338 (10-2007) <br /> <br />Name of Non-profit Organization <br />ilJ c- 1< S \!:J r../ I "2 S"' -Ih.. Ft-n n ; ve.r~l <br />Person Responsible for the Gaming Operation, Including Disbursrent of Net Inc e <br />, t-"n<nl Il>W~e... (m;'n?l~<:. <br />~sjness ddress J) <br />1--1 c!.""e 5' , ~ -rR. rf> /: ~~ <br />Mailing Address (if different) <br /> <br />/ <br /> <br /> <br />~al Permit <br /> <br />Application for: <br /> <br /> <br />Name of Site Where Game(s) will be.fonducted <br />P. c 1:. Se (~~./. <br />City <br /> <br /> <br /> <br />* D Charity Local Permit <br />Date(s) of 1ctivity <br />CJh3 08" <br /> <br />(one event per year) <br /> <br /> <br />to t1 - I 3 - 0 <br /> <br />Title Business Phone Number <br /> '""101 4 i:Jz. ~ 2.0,3 <br />City State Zip Code <br />~c.k.s C'.~ 1'/]) S- j"tJ 4J 7 <br />City State Zip Code <br />Site Address f0, ,I) ~ I j 12 t's..5 <br />State County tAS':::> <br />K.D <br /> <br />Check the Game(s) to be ducted: * Poker, Twenty-one, and Paddlewheels may be Conducted only by a Charity Local Permit. <br />o Bingo affle 0 Calendar Raffle 0 Sports Pool 0 Poker * D 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 />'l-4I!)t tAS~ 5'c 0 - <br /> ~:5l -z.sO .- <br /> ,> ~""" V h...tJ) Z-co - <br /> t.l) -' e.iJ.. L~ l - <br /> ,5'" <br /> <br />D Paddlewheels * <br /> <br />Game Type Description of Prize Retail Value of <br /> Prize <br /> (limit $12,000 per year) <br /> Total: $ IO-z..S~ 0.00 <br /> <br />Intended uses of gaming proceeds: <br /> <br />te.,;"J.....f'2..r~~.. ~ <br /> <br />4:< <br /> <br />,LJ.,..".", V ..4 S A7~Y <br />./ <br /> <br />Does the organization presently have a state gaming license? ~ 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? l!'fNo DYes - 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? [B1<fo DYes - 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 />Date J / <br />~ I'2.I,I/b a' <br /> <br />e,1 <br />t~,#~ <br /> <br />Title <br />h? ~,..,LA.. <br /> <br />