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Ga~r1 Jf~~::\. ,. <br />,=:%..~ ~-~`~~: APPLICATION FOR A LOCAL <br />~,~.,`i~~~_,~ i OFFICE OF ATTORNEY GENERAL <br />""~-'~ ~ ~~~" SFN 9338 (10-2007) <br />~... _ <br />Application for: <br />1 <br />~cu~a,b1~ -~ Cis ~n~ ,,~ <br />PERMIT OR CHARITY LOCAL PERMIT yJ ~ ~~ ~~ ~~~ <br />~( Local Permit <br />Name of Non-profit Organization Date(s) of Activity <br />~ ~ %o ' ~ /~ <br />Person esponsible for the Gaming Operation, Including Disbursement of Net Income Title Business Phone Number <br />~~ ~oo~,~, ct>~~,~ ~~~ -~>~~-S8s <br />Business Address City State Zip Code <br /> <br />Mailing Address (if different) City State Zip Code <br />Name of Site Where Game(s) will be Conducted <br />R Q, ~ <br />fd Site Address <br />~ <br />~ <br />1~ <br />~ <br />~~, ~ ~ ;y u; s , <br />~ <br />, <br />u; <br />City State Zip Code Cou ty <br />~5 / ~07 ~ri SS <br />Check the Game(s) to be Conducted: * Poker, Twenty-one, and Paddlewheels may be Conducted only by a Charity Local Permit. <br />^ Bingc 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 Retail Value of <br />Prize <br />C t GiI <br />~ l~ y k ! Ob <br />c ,'o <br /> <br /> <br /> <br /> <br /> <br /> <br />Intended uses of gaming proceeds: ~ ~ ~ G t7 ~~ ~ ~ w ; <br />11~~ ~ ll~~-~~ <br />Does the organization presently have a state gaming license? ~No ^ Yes - If "Yes," the organization is not eligible for a local permit or charity local <br />permit and should call the Office ofAttomey 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 30?~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 city 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: $ .This amount is part of the total prize limit of $12,000 per year. <br />c <br />Signat of Organ' ation's p xecutive Official Date Title ~ ~1~ <br />' <br />S Business Phone Num<b~er <br /> ~ G <br />.- <br />G/ L-~Ti4Q r r ~f~/- ,~~o ~- ,~~Si <br /> <br />1- ~0~1-~$ ). <br />;'~ Charity Local Permit (one event per ~a~) .~ <br />