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e r.' z,"'-:!."i-o, APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT <br /> OFFICE OF ATTORNEY GENERAL <br /> • vo,. SFN 9338(07-2009) <br /> • Application for: ❑ Local Permit *Charity Local Permit (one event per year) <br /> Name of Non-profit Or izatio Date(s)of Activity <br /> Gyle Peterson Il 10/24/2014 to 10/26/2014 <br /> Person Responsible for the Gaming Operation and the Disbursement of Net Income Title Business Phone Number <br /> Corey Eslinger (701)293-9400 <br /> Business Address City State Zip Code <br /> 3317 Feichtner Fargo ND 58103-2328 <br /> Mailing Address(if different) City State Zip Code <br /> Name of Site Where Game(s)will be Conducted Site Address <br /> Knickerbocker Liqour Locker 412 Main Ave <br /> City State Zip Code County <br /> Hickson ND 58047-5103 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 /> loto 4h 11,6y■ Ca s t_o 12 e <br /> rfni. ,,l <br /> (Limit 512,000 per year) <br /> Total: $ 0.00 <br /> Intended uses of gaming proceeds:Benefit for Gyle Peterson, suffers from Muscular Dystrophy. Proceeds to <br /> help fund various medical costs include vision and hearing procedures <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? g No ❑ Yes - If"Yes," <br /> indicate the total val - • - • - • = '• I awarded:$ . This amount is part of the total prize limit of$12,000 per year. <br /> Sig .ture of• j•• -=tion.To. -cutive On Date Title— Business Pho a Number <br /> CIF b 2, <br /> 7ok-440— t742- <br />