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4♦FKT `` <br /> f;r' C� APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT <br /> ','., s,, `j J! OFFICE OF ATTORNEY GENERAL <br /> . ,?s eV SFN 9338(07-2009) <br /> • Application for: ocal Permit *❑Charity Local Permit (one event per year) <br /> Name of Non-profit Organization Date(s)of Activity <br /> C ha- rbi.i Lon GtieI3 / c -- i ,r ' to / •-6 •- /5 <br /> Person Responsible for the Gaming Operation and the Disbursement of Net Income Title Business Phone Number <br /> 5--la r .12 PO a4,-,547 Dir 7e / - 36/- /SS <br /> Business Address City State Zip Code <br /> '159/— IS rte. 5 I,vhJ2.a7tLahiJ JV 5ko7y. <br /> Mailing Address(if different) City State Zip Code <br /> GGName of Site Where Game(s)will be Conducted Site Address �� <br /> E/tt6'DI-h Ftcr/h.er5 Pa Ii0/1) " Cs" -IC. -j07 /✓Ick> ..SIL <br /> City State Zip Code County <br /> �n A/D 5 X07 > Ca 5S <br /> Check the Game(s)to be Conducted: *Poker,Twenty-one,and Paddlewheels may be Conducted only by 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 /> Retail Value of Retail Value of <br /> Game Type Description of Prize Game Type Description of Prize <br /> Prize Prize <br /> airk. 2.- f- <br /> 1 UO V3 50 „ <br /> .2- . 5 v <br /> 2 $ )- 5 <br /> (Limit$12,000 per year) <br /> Total: $ '3S 0.00 <br /> �J �) / Q U <br /> Inten d u es of gamtng pro ds: ,E trr_a,C C�fh /70/u-', �rl�C�( , A52-(2122 _ <br /> Does the organization presently have a state gaming license?s-No ❑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 1-800-326-9240. <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 er year. <br /> Signat Orga ; tion's Top Executive Official Date Title Business Phone Number <br />