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~~ <br />St,~n~ ~ ~ ~ lo,~ - a .. - ~;r~~ ~~ <br />i~>:,,T.~F~, <br />~r~'~"~,~,~ APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT ~~~~ ~rn~~~ ~)~l <br />~i =:`~f~~"~) OFFICE OF ATTORNEY GENERAL <br />\1yf• 1 -sC `y <br />'."~~~~„' SFN 9338 (07-2003) <br />Application for: ^ Local Permit ' ~harity Local Permit (one event per yeaf) ~ ~ <br />Name of Non-profit Organization Date(s) of Activity ~ <br />~~ ~~~~~[~ N f~ FZ'r to 3 I n <br />~ <br />Person Responsible for the Gaming Operation, Including Disbursement of Net Incom e Title Business Phone Number <br />' ~~ ~~~ 0~ ~~~(~~~~7 <br />BusinessAddreas City Stale Zip Code <br />5 ET DR w N~ 580` 7 <br />Mailing Address (if different) City State Zip Code <br />Name of Site Where Game(s) will be Conducted <br />1z <br />t <br />E~ <br />~ <br />K <br />K 1 ( <br />L Site Address <br />~I ~ 2 <br />~V~ <br />- <br />- <br />. <br />U.o <br />k. <br />. <br />-~R Z <br />City <br />S~.~L- D N State <br />D Zip Code <br />o~ ~ County <br />r1.RSS <br />Check the Game(s) to be Conducted: "Poker, Twenty-one, and Paddlewheels may be Conduct only 6y a Charity Local Permit. <br />^ Bingo ^ Raffle ^Calendar Raffle (]Sports Pool Poker • ^ Twenty-one" ^ Paddlewheels ' <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br />Game Type Description of Prize RPtaii Value of <br />Prize <br />i~~S ~~ ~ ~ S l7 <br />Intended uses of gaming proceeds: L~ ~(; K ~ ~ ~Q ~ Y-r ' !i_-S <br />h <br />Does the organization presenty have a state gaming license? ~'~lo ~es - If "Yes," the organization is nat eligible for a local permit or charity local <br />permit and should call the Oifice of Attorney General at 1-B00-328-9240. <br />Has the organfzalion received a charity local permit from this or another dry or county for the fiscal year July 1 through June 307 ~No ^ Yes- If "Yes," <br />the organization does not qualify for a local permit or charity local permit. <br />Has the organization received a local permit from this or another dty or county for the fiscal year July 1 through June 30? No ^ Yes - If "Yes;' <br />indicate the total value of all prizes previously awarded: S .This amount is part of the total prize limit of 312,000 per year. <br />Signature of OlIrgan tj'~n's T~Executive OfFidal <br />~ Date <br />` <br />~ <br />~ Title <br />~ <br />~ <br />~ Business Phone Number <br />--- - I ~ 1~ P IL~ III.1 0 <br />~ <br />9 <br />2 ~-v~ 9'v~ <br />~. ~ <br />, ` 1- l ~ gy$ ~ <br />°~/~ <br />- ..- <br />