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<br />b~m)+ i lo-OOajJp),"M,'On ra, <br />f~L1b}i it> CaJ'S~unhJ 'ftu&fot <br />APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT W;}}t Cof\1~ )vreA <br />OFFICE OF ATTORNEY GENERAL f11N!J"UZJ;& <br />SFN 9338 (10-2007) --f r <br />Application for: ~. Local Permit * 0 Charity Local Permit (one event per year) <br />Date(s) of Activity <br /> <br /> <br />!r'l~j <br />~...a~~ ._;. <br />\"i;'(;~~ii~~~':( <br /> <br />'/ .sF <br />f\ ,J.k~ <br /> <br />",-, 0 "'- <br /> <br />:1- I{-o <br />Title <br /> <br />to /:L - -1:)0' <br /> <br />City <br /> <br /> <br />~l~J~~ j <br /> <br />State <br />"1[7. <br /> <br />Zip Code <br />~ go7 <br /> <br />Site Address <br /> <br />State Zip Code CO;!f'}Y <br />~ , D-}(, ".. '< S-3 07 c.::~ >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 ~e DCalendar Raffle 0 Sports Pool 0 Poker * 0 Twenty-one' <br /> <br />Erl b/.elt <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 /> <br />o~, <br /> <br />;2- <br /> <br />o Paddlewheels' <br /> <br />Game Type Description of Prize Retail Value of <br />Prize <br /> Total: fI.$12.000 per year) <br /> $ :3 5tJ. 0.00 <br /> <br />Intended uses of gaming proceeds: <br /> <br />~ 'L ~~ .""- ~ <br /> <br />~ <br /> <br />1\ ~~7 <br /> <br />Does the organization presently have a state gaming license? 0 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 Attomey 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? 0 No 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? 0 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 />s Top Executive Official <br /> <br />~.5:o~ <br /> <br /> <br />