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<br /> <br />y~ ;l Ù 1-- ~O ¡ tV 10 CU app! ¡(it£¡ ön f<i/ ~JJat {¿t <br />APPLICATION FORA LOCAL PERMIT OR CHARITY LOCAL PERMITlh~~1ÛJUlI11J '{)jj¡~'1t/ <br />OFFICE OF ATTORNEY GENERAL <br />SFN 9338 (07-2003) <br /> <br />Application for: <br /> <br />¿ocaf Permit <br /> <br />" 0 Charity Local Permit (one event per year) <br />Date(s) of Activity <br />'-1- I Î -0 ~( <br />Title <br />C G MM.' ,he <br /> <br />Name of Non-profit Organization <br /> <br />(VI 'Cuó~l ,?ÇLul)\~ é.JwG",f( (2c-r40 <br />Person Responsible for the Gaming Operation, Including Disbursement of Net Income <br />ß¡e~c...1 ~L~~".J\. <br />Business Address <br />;7c, ~- ¡vv, w <br />Mailing Address (if different) <br /> <br />i. ~ <br /> <br />W/L[) <br /> <br />f2\CL <br /> <br />City <br />lA,) I I..J) <br />City <br /> <br />/2\c L <br /> <br />to <br />Business Phone Number <br />M~~";¡ d~ '7 - 5fYìG <br />State Zip Code <br />~Ü S¡?o'-iÎ <br />State Zip Code <br /> <br />Name of Site Where Game(s) will be Conducted <br />W ( L-O (è \ cL ~ R '\ C-)~? i LL <br />City <br />Cv I LÙ (>ü:\.. <br />Check the Game(s) ~7Conducted: <br />0 Bingo h,jRaffie <br /> <br />Site Address <br />;;>0'5 ¡\11 ð vJ <br />State I ZiP. Code I County <br />AJD 52f~'1 ì CL~ S <br /> <br />* Poker, Twenty-one, and Paddlewheels may be Conducted only by a Chañty LoCal Permit <br />B'6alendar Raffle D Sports Pool 0 Poker * 0 Twenty-one * <br /> <br />0 Paddlewheels' <br /> <br />DESCRIPTION AND RETAJL VALUE OF PRIZES TO BE AWARDED <br /> <br />Game Type <br /> <br />Description of Prize <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 />(2!) çp \ 'l I\J (; IY\ :,e~»- ~ $ ø -4 .:..jO ,.~ CI¡1YJ .Db ffW <br /> <br /> <br />øtc:.> ,1);)( ß W, '{ L-/SO'-:: é'1)ßll~ Cf/', 11 SO ,,~ <br /> <br />$ <br /> <br />(Umit $12,000 per year) <br />Total: $ u . > ciA" , J <br />tJ I ,€a) .00 JhV <br /> <br />Intended uses of gaming proceeds: 'Tú .utLp ,'rJ.)<¿ ßd-'~'( cC ¡V!1(u<)'{L (\¡;;co,Wì6 Ct-,,¡,.-R ,Ll;:;,fI'J!}L.", <br /> <br />A-st) ' e'l~[ L f Jrp"Ii>< ~ D'~L 'Tt rJ' 50 (f/~i'!¡S <br /> <br />Does the organization presently have a state gaming license? ~o 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 1-800-326-9240. <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? ~ 0 Yes - If.Y es,. <br />the organization does not qualify for a local permit or charity local permit <br /> <br />Has the organization received a local permit from this or another city or county for the fiscal year July 1 through June 30? ~ Dyes - 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 /> <br />I Sig~e of Organizati~n's Top Exef\tive Official <br />Ú cL... , f( Itft..-. <br /> <br />I Date <br />J/-&..".{ <br /> <br /> Title <br />kc "",,~,Jtt <br /> <br />Æ,fýrv'\()d(. <br /> <br />I Business Phone Number I <br />~ S7- ~l/7(J <br />