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<br />~l~ <br /> <br />b~bm;+ i 10.00 awrt1:tJ-,-(1) ~ft, <br />~CMJab}i ~ CaJ^S~Ut1fy ftu&~( <br />APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT vJ; +}1 &f\1y, )e;teJ. . <br />OFFICE OF ATTORNEY GENERAL '()j),j I (Catl rJt <br />SFN 9338 (10-2007) nf( <br />Application for: )?J: Local Permit * D Charity Local Permit (one event per year) <br /> <br />Name of Non-profit Organization <br /> <br />Date(s) of Activity <br /> <br />1-;4-t:? <br />Title <br /> <br />to I-~~-~? <br />Business Phone Number <br /> <br />L t5"5"' C (7h-/Vr L, - C t-, ,!j <br />Person Responsible for the Gaming Operation, Including Disbursement of Net Income <br />/... of ,f.A//f ~* 5"7'.E .R IV /i' "e <br />Business Address City <br /> <br />'/""fir C #,d.,.I/M <br /> <br />.?~'l- ~?/t5 <br />State Zip Code <br /> <br />wF~T r"..e~c <br /> <br />City <br />C,f'f~n?/'7,v <br />Site Address <br />/2 ~I t.P$~r <br />Zip Code <br />17~'? r <br /> <br />State <br />/VI) <br /> <br />Zip Code <br />~!fR'/.2. <br /> <br />Mailing Address (if different) <br />JJ~ <br />Name of Site Where Game(s) will be Conducted <br /> <br />,f~-1. . Vii" ,4 JI,I- t- oF "oR &AeN-,-v,t;!. <br />City <br /> <br /> <br />State <br />{1/(l <br /> <br />/f14>-', ;'P'~ <br />County <br />c.".~~ <br /> <br />Check the Game(s) to be Conducted: * Poker, Twenty-one, and Paddlewheels may be Conducted only by a Charity Local Permit. <br />D Bingo ~Raffle DCalendar Raffle 0 Sports Pool 0 Poker * 0 Twenty-one * <br /> <br />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 />RIFF?& CA ;;- # ' t "'~e:P <br />/(frr?,ff C#)'/)t :J1 I tt:J d iJ <br /> <br />Game Type Description of Prize Retail Value of <br /> Prize <br /> (Umit $12,000 per year) <br /> Total: $ :? t'DO.OO <br /> <br />Intended uses of gaming proceeds: to,*L.-()L iF.. P""'/J'I/.vCfhu';:n--1 ;J1V'4 y,,,,,,# fi/J...e'f,,^h''--' 4-.0 <br />Y,e,.. 7tlf C #JII"1/$' .1----11 (jc 7"1"",0r-~ ~or-' <br /> <br />Does the organization presently have a state gaming license? ~ No 0 Ves - 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? ~ 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 I8f Yes - If "Yes," <br />indicate the total value of all prizes previously awarded: $ 9CJ1!:J~ ~ This amount is part of the total prize limit of $12,000 per year. <br /> <br /> <br /> <br />Business Phone Number <br />Jy?~trP/~ <br />