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�'fk' s� APPLICATION FORA LOCAL PERMIT OR CHARITY LOCAL PERMIT <br /> 14�r."`;_ ' i ;. OFFICE OF ATTORNEY GENERAL <br /> \c,a .sec.;%' SFN 9338(074009) <br /> - Application for: ❑Local Permit * ]Charity Local Permit (one event per year) <br /> Name of Non-profit Organization Dale(s)ofActivity <br /> Social Justice Committee St.Benedict Church Of Wild Rice 4/13/2014 to 4/13/2014 <br /> Person Responsible for the Gaming Operation and the Disbursement of Net Income. Title Business Phone Number <br /> Father Jared Kadiec Priest/ceo (701)588-4288 <br /> Business Address City State Zip Code <br /> 11743 38th Street South Horace 4 ND 58047-9512 <br /> Meiling Address(if different) City State Zip Code <br /> Name of Site Where Game(s)will be Conducted Site Address <br /> St.Benedict Church of Wild Rice 11743 38th Street South <br /> City State I Zip Code I County <br /> Horace ND I 58047-9512 I Cass <br /> Check the Game(s)to be Conducted: •Poker,Twenty-one,end Paddlewheels may be Conducted only by a Charity Local Permit. <br /> 0 Bingo ®Raffle 0 Calendar Raffle 0 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 Prize Game Type Description of Prize Prize <br /> raffle quilt $500.00 <br /> raffle Keurig $150.00 <br /> raffle gift cards $200.00 <br /> raffle gift basket $150.00 <br /> • <br /> (LW tn2.aOOyeryowl <br /> Total: $ 1,000.00 <br /> Intended uses of gaming proceeds:fulfill needs of people:hunger, homelessness,foster care,etc. (4-116oua1h co a. <br /> J 1.LQ1'cIL (mfr.: 'P,e) ✓ <br /> Does the organization presently have a state gaming license?®No ❑Yea• 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 1-800.328-9240. <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 riot qualify for a local permit or clarity 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 ❑ Yea- If"Yes,' <br /> indicate the total value of all prizes previously awarded:$ . This amount is pert of the total prise limit of$12,000 per year. <br /> Sigis of Organization Top Ex=. I •ificlal Date Title Business Phone Number <br /> rz n r , �,/0�� 3/6/2014 Prlest/ceo (701)586-4288 <br />