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<br />(I)) <br /> <br />b~bm/+ ~ 10.00 awrtZttlOI) ~e6 <br />fCtlJ(1~}t 11> CaJ'S~unhj 'f1u&for <br />APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT 'vJ; +}l cpfI(1vJ )vteA <br />OFFICE OF ATTORNEY GENERAL VllNj-I'"j. ',0" <br />SFN 9338 (10-2007) _vH ) v.r;/' ()'7 <br />Application for: 13 Local Permit * D Charity Local Permit (one event per year) <br /> <br />Name of Non-profit Organization Date(s) of Activity /fJ-lf-O</' <br />Nt? '('(L L u... i11 e;ra.rt C h U-V" c..- k I~-t.t-D~ to <br />Pen Responsible for the Gaming Operation, Including Disbursement of Net Income Title Pre... .. Business Phone Number <br />. tJ V1V1I\~ O......l\ l.L'YV\ UJ E3 L(.A AI 'i' 'I - '5' 53 5 <br />BUS;n?;S ~prrs 15 '" Sf Cit; d State zi3c~~ 3 b <br />SE OL.-.{ . V\~ ND <br />Mailing Address (if different) 15,-u')f 5 E City State Zip Code (;, <br />[)Y1a-El '.e+1 >ern /J?{)~I GQ~~J v1.e. r- /I\) 5tg'o ~ <br />Nam~ Site Where Game(s) will be Conducted Siti~~es~ J t ". s1 'Sf: <br />/ /!) V'<A... L lA.- ~~ C h VLV' e-k. <br />City GaAA State I Zip Code COU& <br /> Yl~y HD. 5'c:ro '7 Co 5:5 <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 )K1 Raffle DCalendar Raffle o Sports Pool o Poker * D Twenty-one * 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 />l{ cz tel'l GO-$ Ca.~c:\ It pc, <br />. bp. - <br />I' L,' Yl~ gQ5~~ 75. {J,. <br />~ <br />1\ ~~~ ;.5. 0& <br />- <br /> 'J <br /> <br />Game Type Description of Prize Retail Value of <br /> Prize <br /> (Limit $12,000 per year) <br /> Total: $ ...., --."" <br /> . <br /> <br />u. "v <br /> <br />Intended uses of gaming proceeds: <br /> <br /> <br />.~ <br /> <br /> <br />Does the organization presently have a state gaming Iicense'f'~o 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 1-80~~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? )6 No 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? 0 No Ik1 Yes - If "Yes," <br />indicate the total value of all prizes previously awarded: $ 20 () . ~ . This amountis part of the total prize limit of $12,000 per ye~ <br /> <br /> <br />Date <br />~ - ((P.- () <br /> <br /> <br />Title <br />[A/GU4 <br /> <br />V .e -S l.h-A<.:1 <br /> <br />Business Phone Number <br />1.fc{~~ zS63S <br />