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f.: APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT <br /> : .!1 OFFICE OF ATTORNEY GENERAL <br /> SFN 9338(07-2009) <br /> • <br /> • IgCN� <br /> Application for: L°l Local Permit `❑Charity Local Permit (one event per year) <br /> Name of Non-profit Organization Date(s)of Ac� l , <br /> High Plains Regional Rendezvous 6/14 to 6/21/2014 <br /> Person Responsible for the Gaming Operation and the Disbursement of Net Income Title Business Phone Number <br /> Monty Mertz (16)) aq LiL,Li() J614) `'wit!Jam/ (' /y.. Clerk (701)232-2724 <br /> Business Address City State Zip Code <br /> 2716 64 Ave South Fargo ND 58104-xxxx <br /> Mailing Address(if different) City State Zip Code <br /> 2716 64 Ave South Fargo _ ND 58104-xxxx <br /> Name of Site Where Game(s)will be Conducted Site Address <br /> High Plains Regional Rendezvous/Warren Solberg Farm 11601 25th Street South <br /> City State Zip Code County <br /> Wild Rice ND 58047-xxxx 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* ❑ 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 Gun 50 caliber $1,500.00 <br /> Raffle Quilt $150.00 <br /> Raffle Long Bow/Arrows $300.00 <br /> (Limit$12,000 per year) <br /> Total: $ 1,950.00 <br /> Intended uses of gaming proceeds: Proceeds will help off set the costs of land preparation, and event <br /> prizes for the 800 participates expected to be at the event <br /> Does the organization presently have a state gaming license? M 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 /> Signature of Organization's Top Executive Official Date Title Business Phone Number <br /> —4*()7214.-- <br />