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<br /> <br />LOCAL PERnlllT OR CHARITY LOCAU:>ERMIT <br />OFFICE OF ATTORNEY GENERAL <br />SFN 17926 (02-2002) <br /> <br />Type: <br /> <br />IXkLocal Permit <br /> <br />*0 Charity Local Permit <br /> <br />Permit Number <br />395 <br /> <br />Name of Organization <br />Four Corners Wildlife <br />Contact Person <br />Mark Levos <br />Mailing Address <br />,14659 42nd Street SE <br /> <br />Date(s) Authorized (Read instruction 2) <br /> <br />Club <br /> <br />Business Phone Number <br />701-238-3214 <br />City <br />Wlieatland <br /> <br />~/~/~to <br /> <br />Site Name <br />Embden Senior Center <br />City <br />Embden <br />Check the Game(s) Authorized: <br /> <br />Site Address <br />RR <br /> <br /> <br />2 I 4 <br />- Eiidii1 <br />Zi~ S:8'7"9 <br /> <br />I 06 <br /> <br />State <br />ND <br /> <br />Zip Code <br />58079 <br /> <br />County <br />Cass <br /> <br />.. Poker, Twenty-one. and P~ddlewhee.1s may be Conducted only by a Charity Local Permit. <br /> <br />!Xl Bingo <br /> <br />!QI.:Raffie <br /> <br />o Calendar Raffle <br /> <br />D Sports Pooi <br /> <br />D Poker- <br /> <br />o Twenty-one' <br /> <br />o Paddlewheels' <br /> <br />RestrictlOfl: <br /> <br />Requirement For a "Charity Local Pennit," the organization must file a "Report on a Charity Local Pennit" with the city or county auditor and Office of <br />Attorney General within 30 days of the event. <br />Date . Signature of; D - Auditor ~ County Auditor Printed Name of City or County Auditor Auditor Telephone Number <br />1 I 17 I ~/:: ,;/ _".. ~~~ Michael Mont laisir 701-241-5601 <br />For a raffle or calenda ~ff1e, read "In ormation Required to be Preprinted on a Standard Raffle Ticket" on the backside of the form. <br /> <br />INSTRUCTIONS: <br /> <br />After a city or county governing board has authorized an organization to receive a local permit or charity locai <br />permit, the city or county auditor must complete this form, <br /> <br />1. Enter the city or county assigned "Permit Number." <br /> <br />2. Enter the beginning and ending date(s) for which the permit is authorized. <br /> <br />a. For other than a .calendar" raffle that may be authorized for January 1 to December 31, a local <br />permit or charity local permit cannot be authorized beyond June 30, <br /> <br />b, For a "one time" raffle, the beginning and ending dates for "Date(s) Authorized" is the date of the <br />prize drawing. <br /> <br />c, A local permit can be issued for one or more events per year, <br /> <br />d. If a local permit is issued for more than one event, enter the date of the first event as the <br />"beginning" date and the date of the last event as the "ending" date, <br /> <br />e. A charity local permit may be issued for only one event within a fiscai year July 1 - June 30. <br /> <br />3. Enter any restriction pi aced on the organization, such as day,S of the week or'designation of an area at a <br />site where games may be conducted, <br /> <br />4. Provide a "Report on a Charity Local Permit" form to the organization. lIf a Charity local Permit, onlv) <br /> <br />5, Make two copies of the completed form, Provide the original form to the organization, keep one copy for <br />the file and, within fourteen days of issuance, maii a copy to: OFFICE OF ATTORNEY GENERAL; <br />LICENSING SECTION; 600 E BOULEVARD AVE - DEPT 125; BISMARCK NO 58505-0040 <br />