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%i' T:'" 't,,, APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT <br /> rt:tl sa':'ti, _t i <br /> ;,,,,�L, . •� .) OFFICE OF ATTORNEY GENERAL <br /> `13,%:,�. 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 /> Sanford Health Foundation 8/22/2014 to 8/22/2014 <br /> Person Responsible for the Gaming Operation and the Disbursement of Net Income Title Business Phone Number <br /> Amy Hinkemeyer _ <br /> Business Address City State Zip Code <br /> Po Box 2010 Fargo ND 58122-2399 <br /> Mailing Address(if different) City State Zip Code <br /> Name of Site Where Game(s)will be Conducted Site Address <br /> Wild Rice Bar&Grill 205 Main Street <br /> City State I Zip Code County <br /> Horace ND _ 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 /> W. set %R , 1i Sr <br /> * 'lh-i-at i t vio- Co <br /> (Limit$12,000 per year) <br /> Total: $ 0.00 <br /> Intended uses of gaming proceeds:Funds raised benefit the Roger Maris Cancer Center <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 307 ®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? IN 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 /> Signs re of Organization's1T p Executive Official Date Title Business Phone Number <br /> -U-A— t,l_k . ,� "7/31 I 1 Li t�'Ue. p;�wo C iC '� •-7G1— 3LI- `� <br />