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t...t....yr, <br /> APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT <br /> OFFICE OF ATTORNEY GENERAL <br /> SFN 9338(07-2009) <br /> Application for: M Local Permit *❑Charity Local Permit (one event per year) <br /> Name of Non-profit Organization Date(s)of Activity <br /> Hickson Days Committee 2Lil2pogJ" )'aO/ to 1.0ka212t3T4 -(31-?O)S Person Responsible for the Gaming Operation and the Disbursement of Net Income Title Business Phone Number <br /> Colleen Brakke (701) 361-5080 <br /> Business Address City State Zip Code <br /> 5060 173 Ave Se Hickson ND 5g 0 Li 7 <br /> Mailing Address(if different) City State Zip Code <br /> Name of Site Where Game(s)will be Conducted Site Address <br /> Knickerbocker 412 Main Ave <br /> City State Zip Code County <br /> Hickson ND 5 0y 1 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 /> Raffle Meat $20.00 <br /> Meat $20.00 <br /> (Limit$12,000 per year) <br /> Total: $ I:,?r O o <br /> Intended uses of gaming proceeds:Hickson Days Events(these are free community events)Give to local people <br /> if in need..Upkeeping of Community Center and other thiings in communittee as needed <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 0 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 f Organization's Top Executive Offici I Date Title Business Phone Number <br /> fux\-K '10 - i '70) - 310-5b2 <br />