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<br />~LLVm i ~ <<10,00 . ^ .. - 'IrJrl-P-~ <br />ftt~tW)t~ (clfDuxttu Ut0,t <br />APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT WJ-th CoY)tr}~ apf)/atf"; <br />OFFICE OF ATTORNEY GENERAL <br />SFN 9338 (07-2003) <br />Application for: <br /> <br />~.,,--~' <br />... '.,..,l\.. <br />!."Z'1..:"'(;!:"~:':<'~" <br />IT( i(~~"'~ \ <br />11 i6A~ ",,1\ <br />\\~'B!'i ;,zi. <br />'~~1:1't' 11. ? <br />. 'W',~o".~ " <br /> <br />o Local Permit <br /> <br />· 0 Charity Local Permit (one event per year) <br />Date(s) of Acllvlty <br />--.5/-0 <br /> <br />Namep(5:~:a:;n ~ ~~ <br /> <br />Person Res sible for ~,.Gaming Operation, Including Disbursement of Net Income <br />___ r.l( 2 ~ t:> <br />Business A dress City <br /> <br /> <br /> <br />- .J/-t/ <br /> <br />Business Phone Number <br /> <br />70/-;).)3"-3 ~ <br /> <br />State Zip Code <br /> <br /> <br />0L~~L~ <br /> <br />Site Address <br /> <br /> <br />Zip Code <br />S J/:)7 <br /> <br />nbcl, <br /> <br />co~~ <br /> <br />. Poker, Twenty-one, and Paddlewheels may be Conducted only by a Charity Local Permit. <br />DCalendar Raffle 0 Sports Pool 0 Poker. 0 Twenty-one. <br /> <br />Check the Game(s) to be Conducted: <br />~ ~e <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br />Game Type <br /> <br />Description of Prize <br /> <br />Retail Value of <br />Prize <br /> <br /> <br />C/ <br /> <br /> <br />$'....5' <br /> <br />o Paddlewheels' <br /> <br />Game Type Description of Prize Retail Value of <br />Prize <br /> (U"'! $12,0:)0 per).." <br /> Total: ~? lJ 0,0.00 <br /> ~ ./ <br /> <br /> <br />Does the organization presently have a state gaming license? ~ 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 1-800-326-9240. <br /> <br />Has the organization received a charity local permit from this or another dty or county for the fiscal year July 1 through June 30? ~ 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? ~'D Yes. If "Yes," <br />indicate the total velue of all prizes previously awarded: $ , This amount is part of the total prize limit of $12,000 per year, <br /> <br /> <br />'Executive Official <br /> <br />Dat,e / <br />/- (". ~C) <br /> <br /> <br />Business Phone Number I <br />. ~/-,<}$1-J2 r <br />