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<br />I)~~::~"\.\ <br />"'~"!' <br />.. ' <br />"...ta.!t; ;4/. '.'.. <br />1~,.... .i" ,..,f" <br />f..' ~.-1,,"~ <br /> <br />APPLICATION 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 />* E Charity Local Permit (one event per year) <br />Date(s) of AdMty <br /> <br /> <br />Nt\) <br /> <br />L- 0 c...l"t. r" <br /> <br />City <br /> <br />.+-ti't.. rc... ~ , ~ <br />Check the Game(s) to be Conduded: <br />o Bingo 0 Raffle <br /> <br />City <br /> <br /> <br />j~c (Ie.. <br /> <br />City <br /> <br />State <br />I') IJ <br /> <br />f<-C) Il (" <br />Site Address <br />Lt t:l \,') '\ <:t '; n.. <br />Zip Code <br />'S~olr2 <br /> <br />H v {' ~,L', -c.. <br />County <br />C C.l S <.; <br /> <br />State <br />NO <br /> <br />* Poker, Twenty-one. and Paddlewheels may be Conducted only by a Charity local Pennit. <br />DCalendar Raffle 0 Sports Pool ~ Poker * 0 Twenty-one * <br /> <br />o Paddlewheels * <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 />e <br /> <br /> <br />~ c,-C' G.. , <br />~J D'-' -Iv\. t; <br /> <br />\ Sc"i . <br /> <br />~ '- ~ ~'I "" <br /> <br />Game Type Description of Prize Retail Value of <br />Prize <br /> (Linn $12.000 per year) <br /> Total: $ 0.00 <br /> <br />Int8ndeduaesofgarnlngproceeds: Or'l",.,..f;cl" +c:, Rt"'Ctj Fm' Lj,ft <br /> <br />Does the organization presently have a state gaming license? [lI No 0 Yes .. If "Yes," the organization is not eligible for a local pennit or charity local <br />pennit and should call the Office of Attorney General at 1-800-326-9240. <br /> <br />Has the organization received a charity local pennit from this or another city or county for the fiscal year July 1 through June 30? ~ No 0 Yes.. If ''Yes." <br />the organization does not qualify for a local pennit or charity local pennlt. <br /> <br />Has the organization received a local pennit from this or another city or county for the fiscal year July 1 through June 30? 6if No 0 Yes.. If "Yes." <br />Indicate the total value of all prizes previously awarded: $ . This amount is part of the total prize limn of $12, 000 per year. <br /> <br /> <br /> <br />Title <br />vP <br /> <br />Business Phone Number <br />7<1/-I../7''/-:j I ?~ ~" /-, <br />