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<br />b~bm;+ $10.00 aJprta+,Oll tt0. <br />fatJa,blt 1-0 Casstl.n,tnf!j ~for <br />APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT vJ ;}}t Corny, lvtr?A <br />OFFICE OF ATTORNEY GENERAL r:U))I/UtZ,f;& <br />SFN 9338 (10-2007) --rr <br />Application for: ~ Local Permit * 0 Charity Local Permit (one event per year) <br /> <br /> <br />.' <br /> <br />i(~~ <br /> <br />Name of Non-profit Organization <br /> <br />c <br /> <br />Ct-u <br /> <br />Ii';e <br /> <br />Business Address <br /> <br />Mailing Address (if different) <br />t:J # CJ >'- <br /> <br />56 <br /> <br />Name of Site Where Game(s) will be Conducted <br />I? IT" '-'4v'/P C~Ph-/V~/ <br /> <br />City <br /> <br />w/i:f'r <br /> <br />~A ~ C/ <br /> <br />Date(s) of Activity <br /> <br />/ - .J- J( -ttJ <br />Title <br /> <br />to /- ) i/ -c; '1 <br />Business Phone Number <br />.?~ 9-~1J /6' <br /> <br />fl ~ C /I;II/~,/l~ <br /> <br />City <br /> <br />State <br /> <br />Zip Code <br /> <br />City <br />C-:J "'" >5" ~ ,-v <br />Site Address <br />l;2p/ Wg-IT <br />State Zip Code <br />ft/dJ S-g G' P g <br /> <br />State <br /> <br />!lit) <br /> <br />Zip Code <br />b~tt:? / ;:L <br /> <br />'tV t/;; <br />County <br />c.#s> <br /> <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 l)(Raffle DCalendar Raffle 0 Sports Pool 0 Poker * D Twenty-one * <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br />Game Type Description of Prize Retail Value of <br />Prize <br />5'#1' ./lTlI'cli't. 5" #/Tli'r 8, 'is/D.-ltt <br /> <br />D Paddlewheels * <br /> <br />Game Type Description of Prize Retail Value of <br />Prize <br /> (Limit $12,000 per year) <br /> Total: $ 0,00 <br /> <br />Intended uses of gaming proceeds: WI't-iJL/F.F #A//I~P/?/F/J-?A:.4:r ~,v# Yt:1~~TH tZih~D.f' 't-~(7W" <br />,+-vI) )I(1JUr# P"-o(;rl9",, ;1--# k""1/,,7,'Hf <br />, <br /> <br />Does the organization presently have a state gaming license? IX'!' 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 at 1-800-526-9240, <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 RI Yes - If "Yes," <br />indicate the total value of all prizes previously awarded: $::: 9' ,pc? ,This amount is part of the total prize limit of $12,000 per year, <br /> <br /> <br /> <br />7'1 ?- t/~/~ <br /> <br />Title fl #F;=Ht <br />~,p-l~J) <br /> <br /> <br />Business Phone Number <br />