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<br />~;+:,~~~.;~,.?r.'., <br /> <br />:( \~.':: <br />.~j!lc~'~ .'to <br />~/'> i' ._.c'$ <br />f.. "tMff\\\.'" <br /> <br />APPLlCA TION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT <br />OFFICE OF ATTORNEY GENERAL <br />SFN 9338 (10-2007) <br />Application for: <br /> <br />o Local Permit <br /> <br />* ti!it Charity Local Permit (one event per year) <br />Date( s) of Activity <br /> <br /> <br />City <br />K CJ \Ct <br />City <br />12., <br />Site Address <br />cd.. t (" 41 ~ i1jU 'j v, !f\V'c h U. 't <br />State Zip Code County <br />N \:J e:;-)s'OY7 (' Ci..~ S <br />. Poker, Twenty-one, and Paddlewheels may be Conducted only by a Charity Local Permit. <br />DCalendar Raffle 0 Sports Pool III Poker. 0 Twenty-one. 0 Paddlewheels. <br /> <br />\0""'--- <br />Business Address <br /> <br />, ft"- <br /> <br /> <br />City <br /> <br />I-\l~ ~ 0 "'" <br />Check the Game(s) to be Conducted: <br />o Bingo 0 Raffle <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br />Retail Value of <br />Prize <br /> <br />Game Type <br /> <br />Description of Prize <br /> <br /> <br /><;t Ida 1'3. lA <br /> <br /> <br />* " <br />St'O.;-1 V\ <br /> <br />'....--' v, <br /> <br />l~ to I q ;;(OD~ <br />Business Phone Number <br /> <br />? <br /> <br />70 <br />State <br />tJD <br />State <br />lJ'D <br /> <br /> <br />S'6$' 7 <br /> <br />Game Type Description of Prize Retail Value of <br />Prize <br /> (Umi! $12.000 per year) <br /> Total: $ 0.00 <br /> <br />Intended uses of gaming proceeds: <br /> <br />f.)Ntl{"ttrOh 1-l"! 12dC"j t='c"V' u.f~ <br /> <br />Does the organization presently have a state gaming license? IE 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 Attorney General aI1-800-326-9240. <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 3D? ~ 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 3D? IX) No 0 Yes - If "Ves," <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 />Business Phone Number <br /> <br /> <br />Date <br />II ~S-"olt <br /> <br />Title <br />vP <br /> <br />7CI-.Lp7-3iCf3,-'( tz <br />