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A� % APPLICATION OFFICE OF ATTORNEY GENERAL FOR A LOCAL PERMIT r OR CHARITY LOCAL PERMIT <br /> �1 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 /> Randy And Jessie Neameyer Benefit 5/17/2014 to 5/17/2014 <br /> Person Responsible for the Gaming Operation and the Disbursement of Net Income Title Business Phone Number <br /> Michelle Aune (701)371-8487 <br /> Business Address City State Zip Code <br /> 506 Sunset Dr. Oxbow ND 58047-0000 <br /> Mailing Address(if different) City State Zip Code <br /> Name of Site Where Game(s)will be Conducted Site Address <br /> Knickerbocker Liquor Locker 412 Main Avenue <br /> City State Zip Code County <br /> Hickson ND 58047-0000 I 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 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 /> Texas Hold Em Cash <br /> (Limit$12,000 per year) <br /> Total: $ 0.00 <br /> Intended uses of gaming proceeds:Neameyer family of St.John, ND lost their home in a fire on 4/18/14 <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 Orga 'zation's Top Executive Official Date Title Business Phone Number r <br /> CY . a 1 . 4/23/2014 (701)371-8487 <br />