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<br />(([~~ <br /> <br />b~bnh+ i 10.00 ftWrta:f,-on ~e0 <br />~~ttb)i -tv CaJ'st't>unty 'f}udt10Y <br />APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT 'vJ; +}1 Cof\1r )et!?A <br />~::~~~(~:;~ORNEYGENERAL ~~)B) &lfrIJ'eaf;t9f <br /> <br />Application for: moca' Permit * D Charity Local Permit (one event per year) <br /> <br />Name of Non-profit Organization <br /> <br />Date(s) of Activity <br /> <br /> <br />c..; <br />Person Responsible for the Gaming Operation, Including Disbursement of Net Income <br /> <br />13 .4-..KL <br /> <br />I <br />W. <br /> <br />G~.-H.,\... <br /> <br />/t-4t.. <br /> <br />, - ~ 1- '" <br />Title <br />/'NWJ6 <il <br /> <br />to / ~ 31 ~ 01 <br /> <br />~ <br /> <br />City <br />Wid) <br />City <br /> <br /> <br />Business Phone Number <br />-<i?l{-=\-C <br />Zip Code <br />~04 '1... <br />Zip Code ..-1 <br />.:)~O-<.( -1 <br /> <br />S:.c \.l A"^- ell. <br /> <br />Business Address <br /> <br /> <br />~ <br /> <br />I2\C L <br /> <br />State <br />1\\0 <br /> <br />Mailing Address (if different) <br />~ s;- JII'I'^' <br />Name of Site Where Game(s) will be Con~ucted <br />c..(.. 12. 6~( l... L <br />City <br /> <br /> <br /> <br />State <br />f\f'l) <br /> <br />t<...- lc. <br />Check the Game(s) to be~ducted: <br />D Bingo ~affle <br /> <br />County <br />C4-~ s <br /> <br />* Poker, Twenty-one, and Paddlewheels may be Conducted only by a Charity Local Permit. <br />DCalendar Raffle D Sports Pool 0 Poker * D Twenty-one * <br /> <br />D Paddlewheels * <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br />Game Type Description of Prize Retail Value of Game Type Description of Prize Retail Value of <br /> Prize Prize <br />(ki-)It. ..,. - ~!.I /liS q.,t ~fJ50{). ~ ~ J1vl <br /> (Limit $12,000 per year) <br /> Total: $~ 0.00 <br /> gn. UJ ,.hJ <br />Intended uses of gaming proceeds: .1::'01"" a,ll( oj :::rIM o4A <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 />Has the organization received a charity local permit from this or another city or county for the fiscal year July 1 through June 307 No DYes - If "Yes," <br />the organization does not qualify for a local permit or charity local permit. ~ <br />Has the organization received a local penmit from this or another citv or county for the fiscal year July 1 through June 30? DYes - If "Yes," <br />indicate the total value of all prizes previously awarded: $ ~_. . This amount is part or the total prize limit of $12,000 per year. <br /> - . <br /> <br /> <br />xecutive Official <br /> <br /> <br />Title <br />_~ ~o~ J'r'-MJcl\.... <br /> <br />Business Phone Number <br /> <br />~3'-~Y:Jo <br />