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APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT <br /> =f 4 OFFICE OF ATTORNEY GENERAL <br /> .te4 SFN 9338 (07 2009) <br /> Application for: Local Permit Charity Local Permit (one event per year) <br /> Name of Non profit Organization Date(s) of Activity <br /> Cowboyup 11/29/2013 to 11 /29/2013 <br /> Person Responsible for the Gaming Operation and the Disbursement of Net Income Title Business Phone Number <br /> Leroy Turner (218) 995 2653 <br /> Business Address City State Zip Code <br /> 1746160th St. Wolverton MN 56594 9564 <br /> Mailing Address (if different) City State Zip Code <br /> Name of Site Where Game(s) will be Conducted Site Address <br /> Knickerbocker Liquor Locker 412 Main Ave <br /> City State Zip Code County <br /> Hickson ND 58047 0000 I Cass <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 ā¯‘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 /> Texas Holdem $100 Buy -In <br /> Seating approx <br /> 150 people <br /> Final prize amount <br /> based upon of <br /> entries. <br /> (Limit 512,000 per year <br /> Total: 0.00 <br /> Intended uses of gaming proceeds: Cancer Research <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- 800 326 -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 per }rear. <br /> Signature of Organization's Top Executive Official Date Title Business Phone Number <br /> 10/14/2013 (218) 995 -2627 <br />