Laserfiche WebLink
1 <br />,~.__.. ~- 1 r <br />(~,JI/ 1~ -~-o Cis ~n~ ~}UG~ <br />~~F ' y<~~ <br />f ~s~~ ~f>t ~; APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT yJ;.~h ~j~~ 1~Qd <br />,~ ~~~~ ,~. OFFICE OF ATTORNEY GENERAL ~~)-~y~'~ <br />f..' ~ ', SFN 9338 (10-2007) `^'t'f _I <br />n,. 4 0~. <br />,::,.:.,vggt~~,,.. <br />- Application for: Local Permit "' ^ Charity Local Permit (one event-,~er year) <br />Name of Non-profit Organization <br />C ~s s Cd ~ ~• ~ 5-~ ~ c <br />Scx.;i, e Date(s) of Activity ~ <br />~ ... ~ ~ ~ ~ ~ to -~ . ~, .ZV ~ y <br />Person Responsible for the Gamin Operation, Including Disbursement of Net Income <br />- ~j ~~ c!Z LJ lr~t. t ~G1 V j l~l Title Business Phone Number <br />Business Address ~ ~ ~ l <br />~~~, VVQ 1 ~~~ City <br />~.SI ~f~ C, State <br />~~ Zip Code~1 <br />S~v 7 <br />M- anilin//g\\Address (if different)(^ <br />V l~X ~1_I City <br />~S1 ~t~t~l~ State <br />~ Zip Code <br />5 <br />Name of Site Where Game(s) will be Conducted Site Address <br />Ci <br />ES.~r ~' I~'ZCn ~ State <br />~7 Zip Code <br />5~a7 ~ County <br />~S S <br />Check the Game(s) to be Conducted: * Poker, Twenty-one, an d 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 />r~~~ f~ ~ ~ L-rl ~ n Ov <br />Intended uses of gaming proceeds: ~~ <br />w~ 5 <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- -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 $12,00 per year. <br />Sign re of Organz ti 's op E ec a Official Date Title <br />~~ Business Phone umber <br />~ <br /> ,~~ ~fi~ <br />+YertD' ~~SoZ' ~ <br />~ ~-- <br /> <br />