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APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT <br /> OFFICE OF ATTORNEY GENERAL <br /> • `,yd- 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 /> Relay For Life(microlap Technologies Team 1) 3/1/2014 to 3/2/2014 <br /> Person Responsible for the Gaming Operation and the Disbursement of Net Income Title Business Phone Number <br /> Tom Neameyer Vp (701)477-3193 <br /> Business Address City State Zip Code <br /> 213 1st Street Nw Rolla ND 58367-0280 <br /> Mailing Address(if different) City State Zip Code <br /> Po Box 280 Rolla ND 58367-0280 <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 58047-5128 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 SE AWARDED <br /> Retail Value of Retail Value of <br /> Game Type Description of Prize Prize Game Type Description of Prize Prize <br /> Texas Hold-em Prize amounts <br /> • dependant upon# <br /> of participants. <br /> (Limit$12,000 per year) <br /> Total: $ 0.00 <br /> Intended ami :.s: ( i / i t Ufl / ��.. i I v ct:!/1 0.4 rgi l Q WI <br /> A . -r, Id # <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 /> Signature of Or9"on's Top Ec 've Official Date Title Business Phone Number <br /> ,fr 2/20/2014 Vp (701)477-3193 <br />