d. Permit for bingo/raffle - Laserfiche WebLink

APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMIT OFFICE OF ATTORNEY GENERAL SFN 9338 (07-2003) Application for: [] Local Permit * [] Charity Local Permit (one event peryear) Pemon Responsible for the Gaming Operation, Including Disbursement of Net Income Title Business Phone Number Bruce Sch~±e Advisor 428-3177 Business Address City State Kindred ND zi58051 DCode 55 1st Ave S Mailing Address (if different) City State Zip Code Name of Site Where Game(s) will be Conducted SiteAddress Kindred School 55 1st Av~. City State ~Z' Code I County Kindred NDJ ~8051 I 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* r']Twenty-one* [] Paddlewheels * DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED Game Type Description of Prize Retail Value of Prize oO Game Type Description of Prize Retail Value of Prize $ ' I (L ~lt $12,00 0 p e,~r) Intended uses of gaming proceeds: Does the organization presently have a state gaming license? ~ No [] Yes - If "Yes," the organization is nct 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? [] No [] Yes - If "Yes," the organization does not qualify for a local permit or charity local permit. Has the organization received alocal permit from this or another city or county for the fiscal year July I through June30? [] No [] Yes - If'Yes," indicate the total value of all prizes previously awarded: $ . This amount is pa~t of the total pdze limit of $12,000 per year. IS ignature organization's Top Exec~f//_Offi~l D ate , .~ Title IB._usiness Phone Number /