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<br />illU' VIII U' 4íll u.v(JV"i1(.V~':JW)J¿ ii <br /> <br />l~~~ \ APPLICATION FOR A LOCAL PERMIT..OR CHARITY LOCAL PERMITQX~J ÙJUMj rlM/-b{ <br />«< OFFICE OF ATTORNEY GENERAL <br />~þ ~ '" SFN 9338 (O7-2003) /"/ <br />~9r_~. _/ <br />Application for: 0'Local Permit .. 0 Charity Local Permit (one event per year) <br />Name of Non-p~ Organization j¡ () í;) I Date(s) ot Activity ¡1fo II, ~ <br />Þlltf (..IO,/lofJ'. 1N:f l'f~ ~(~" I'\,,-r-{t Þ~k, tjH-/~~jï'1rtv~J..to cÂOðý <br />p~on Responsible,for the paming Ope[ëlR9{1. Indu(n;6i,burserrìént of Net Income Title . B~ess Phone Number <br />¡f ý~Y\. ÇcL (~.J'z. -f: ~ Y \e...v!( L ~ ,r .. .s. ff~ , ..¡. v,( ~r(f", 7o(-/~.?-.>..s-/~ <br />Bisiness Address City State Zip Code <br /> <br />Mailing ~j1ress jf differen~ .¡ / ' F <br />Jij¡.>T f~ s $¿ <br />Na~ of ~ite 'jJhere G~e(s) wi~be Conducted <br />Z /4"( btk'l ~ 1'-i , <br />City \/ "" '" (./ State /ZiP Code I Cou~ <br />E ¡VI Þ~,. r' \ UC\.^ , Cc...sS <br />I <br />Check the Game(s) to be ~ucted: * Poker, Twenty-one. and paddle.Wheels may be Conducted only by a Charity Locaf Permit <br />~ngo ~f e DCalendar Raffle ~rts Pool 0 Poker. 0 Twenty-one * 0 Paddlewheels. <br /> <br />~\~a/¿~j <br /> <br />~~~ ~C;~~ <br /> <br />Site Address <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br />Game Type <br /> <br />I Description of Prize <br /> <br /> r 7~J noLi 7?~ $ <br />1164';- R~~ I <br /> <br />Retail Value of <br />Prize <br /> <br />Game Type <br /> <br />Description of Prize <br /> <br />Retail Value of <br />Prize <br /> <br />;t: I;: <br /> <br />¿¡F ¿J - <br />5' 0, <br /> <br />$ <br /> <br />8ìð ß~c_{ $70, <br />ß; [Jo¿;z -f" ç V f <br />L pv~ >1 1tA541f.t <br />fd-:! ~.J' -< I' -#'" 5"'0 ¡ <br /> <br />~tj12,OOO per year) <br />Total:r6Yò¡, <br /> <br />Intended uses of gaming proceeds: <br /> <br />¡j~ f1 ,~ ... <br /> <br />~~ <br /> <br />¡(~~,£-/ ;(;Äc,~ ~ <br /> <br />;1/ .:> .7'y'o.... ~ <br /> <br />......---'-' <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />Does the organization presently have a state gaming license? !3No 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 1-80(þ326-9240, <br /> <br />Has :he organization received a charity local permit from this or another city or county for the fiscal year July 1 through June 30? ~ó 0 Yes - If "Yes,' <br />the organization does not qualify for a local permit or charity local permit L <br />fI- , <br /> <br />Has the organization received a local permit from this or a~other city or county for the fiscal year July 1 through June 30? ØNõ/ ~ - If "Yes: <br />indicate the total value of all prizes previously awarded: S ¡Ä 0 0, ,This amount is part of the total prize limit of $12,000 per year, <br />~ <br /> <br />I s~!j"ature.~ Orgar#ation'S Top ExeaJ,ti~~ Offici~ <br />n~Æ;(~ V'~ f"~<ç <br /> <br />I Date !Tltle <br />I.>-~s- óy t/ ¡<L <br /> <br />r;~ 5 <br /> <br />I Business Phone Number I <br />?¥-J ; IF- 5'-2/rl <br />