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APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT; .� <br /> a..1 OFFICE OF ATTORNEY GENERAL <br /> SFN 9338(07-2009) <br /> Application for: 1$Local Permit *110 Charity Local Permit (one event per year) <br /> Name of Non-profit Organization Date(s)of Activity <br /> Cass County Youth Commission 5/7/2014 to 5/7/2014 <br /> Person Responsible for the Gaming Operation and the Disbursement of Net Income Title Business Phone Number <br /> Charlotte Sandvik Director (701)241-5614 <br /> Business Address City State Zip Code <br /> 211 9th St S Fargo ND 58103-1833 <br /> Mailing Address(if different) City State Zip Code <br /> Name of Site Where Game(s)will be Conducted Site Address <br /> Cass County Highway Department 1201 W Main Ave <br /> City State Zip Code County <br /> West Fargo ND 58078-1301 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 p 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 /> Raffle 32" Fltscrn TV $400.00 <br /> Raffle Fireworks GC $200.00 <br /> Raffle Visa Gift Card $200.00 <br /> Raffle Visa Gift Card $200.00 <br /> Raffle Visa Gift Card $200.00 <br /> Raffle Scheels GC $100.00 <br /> Raffle Scheels GC $100.00 <br /> Raffle West Acres GC $50.00 <br /> Raffle West Acres GC $50.00 <br /> (Limit$12,000 per year) <br /> Total: $ 1,500.00 <br /> Intended uses of gaming proceeds:To Benefit Make-A-Wish Foundation of North Dakota <br /> Does the organization presently have a state gaming license? l3 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? D 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 0 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 year. <br /> Sig0rganization's Top E cutive Official Date Title Business Phone Number <br /> 12/20/2013 Director (701)241-5614 <br />