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"'"',(6,.w.1.l APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT <br /> )a OFFICE OF ATTORNEY GENERAL <br /> x a 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 /> El Zagal Escort Motor Patrol 3/27/2014 to 3/27/2014 <br /> Person Responsible for the Gaming Operation and the Disbursement of Net Income 'Title Business Phone Number <br /> James Rasmussen Exec Comm (701)476-6904 <br /> Business Address City State Zip Code <br /> 1429 3rd St N Fargo ND 58102-2743 <br /> Mailing Address(if different) City State Zip Code <br /> 2325 Willow Rd N Fargo ND 58102-2132 <br /> Name of Site Where Game(s)will be Conducted Site Address <br /> Hickson Community Center Main Street <br /> City State Zip Code County <br /> Hickson ND 58047-0000 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 ['Calendar Raffle ❑Sports Pool ❑Poker• ❑Twenty-one' o Paddlewheels• <br /> DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> Retail Value of Retail Value of <br /> Game Type Description of Prize Prize Game Type Description of Prize prize <br /> Door Prizes Cash $5,000.00 <br /> Raffle Asst Meats $500.00 <br /> Raffle Cash $1,000.00 <br /> (Unit$12,000 per year) <br /> Total: $ 6,500.00 <br /> Intended uses of gaming proceeds:Shrine Unit Expences <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 year. <br /> nature of Organizat ID Top Executive Official <br /> i l Date Title Business Phone Number <br /> 11A� r 12/30/2013 Exec Comm (701)476-6904 <br />