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y"pT SAS ., <br /> ,f: -,- ,;, APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT <br /> tst e---'11.1! OFFICE OF ATTORNEY GENERAL <br /> Y,..- ,' SFN 9338(07-2009) <br /> Nolo <br /> • Application for: ocal Permit *❑Charity Local Permit (one event per year) <br /> Name of Non-profit Organization i 'C Datt�e/(�s)of Activity �r� /�,� <br /> ii f'r-rgrN -�L'Q(Yk.c( 11ifI 1J .010 1 )f 1►ta4 �9t901 to may 7l), r3y <br /> Person Responsib for the Gaming Operation and the Disbursement of -Net Income Title Business Phon Number <br /> 111 t'1 AJ1 Ali 1 p)) (NI-7/0-19-12) Rat (11,;,,r P5sO- )L17) . <br /> Business A ess City State Zip Code <br /> 1 05 rnCti 0 l yr 1NtS\- VCAr N1> 0-1' <br /> Mailing Address(if different) City, State Zip Code <br /> o I3co( 0(Pq FO•IrCiC) �)7 )1c10-1 <br /> Name o ite Where Game(s)will be Conducted Site Addre s <br /> I' 1)(1 I I2v-t.,v Viley kao G-S 1�6 p1, r1 — <br /> City State Zip Code County <br /> 1til e‹.,1-- Farr) N i> _ '--A0-1 CUSS <br /> Check the Game(s)to be C ducted: 'Poker,Twenty-one,and Paddlewheels may be Conducted only by a Charity Local Permit. <br /> ❑Bingo Raffle ❑Calondar Raffle [-J 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 /> \J o 1LL`, oVr.A`\(\0\- <br /> NArtC-(CU 11-to , tC) (Act/8. <br /> • <br /> (Limit$12,000 per year) <br /> Total: $ a 5 p 0.00 <br /> Intended uses of gaming proceeds: a il■ , ■ ♦ • 4 i r I l ' I , ♦ I n►_. <br /> to [rain r103s (fill clac5tc, arc Ton 1-1) . T pollit. 6r P n I )1 f.) - <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 of Attorney 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 3014 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, 0 per year. <br /> Signature of Or a • ati op ecutive Official Date Title^ Business Phone Number <br />