d. Permit for poker-Diamond in the Ruff Pet Rescue

APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT Iu` `hIi OFFICE OF ATTORNEY GENERAL v et„.", SFN 9338(07-2009) 'Na,icN Application for: ❑ Local Permit * p Charity Local Permit (one event per year) Name of Non-profit Organization Date(s)of Activity Diamond In The Ruff Pet Rescue 11/15/2014 to 11/15/2014 Person Responsible for the Gaming Operation and the Disbursement of Net Income Title Business Phone Number Amy Dusek Founder (701)793-0698 Business Address City State Zip Code P. O. Box 6464 Fargo ND 58109-0000 Mailing Address(if different) City State Zip Code Name of Site Where Game(s)will be Conducted Site Address Knickerbocker Liquor Locker 412 Main Avenue City State Zip Code County Hickson ND 58047-0000 Cass Check the Game(s)to be Conducted: *Poker,Twenty-one,and Paddlewheels may be Conducted only by a Charity Local Permit. ❑Bingo ❑Raffle ❑Calendar Raffle ❑Sports Pool © Poker* ❑ Twenty-one" ❑ Paddlewheels* DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED Retail Value of Retail Value of Game Type Description of Prize Game Type Description of Prize Prize Prize Texas Hold 'Em Pc Cash prize $0.00 based on#entry (Limit$12,000 per year) Total: $ 0.00 Intended uses of gaming proceeds:food, supplies and vetrinary care for rescue animals 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 permit and should call the Office of Attorney General at 1-800-326-9240. Has the organization received a charity local permit from this or another city or county for the fiscal year July 1 through June 30? D No ❑ Yes- If"Yes," the organization does not qualify for a local permit or charity local permit. 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," indicate the total value of all prizes previously awarded:$ . This amount is part of the total prize limit of$12,000 per year. Signature of Organization's Top Executive Official Date Title Business Phone Number . � � - 1010 _ t�Ok,r,s t 101- l4 3-06,9b