Laserfiche WebLink
<br /> <br />5c.i~tl\it"JO.0() Q{JpliCti1fMfet,. <br />APPLICATION FOR A LOCAL PERMIT OR CHARITY LOCAL PERMlt~h' tJ~'!'fA I'u.l.- <br />OFFICE OF ATTORNEY GENERAL Wlf ~Dtltpd,~ ~fP 1C()..l11Y <br />SFN 9338 (07-2003) :ff ~t1 <br /> <br />Application for: <br /> <br />~local Pennit <br /> <br />. D Charity local Permit (one event per year) <br />Date(s) of Activity <br />S~ I <br />TWe du,/(f <br />Pr~i<len+ <br />City . <br />I/zJIvfc -e <br />City <br /> <br /> <br />StpI-, 11, JaJ/J <br /> <br />Name of Non.profit Organization <br /> <br />S-';- & I e CtfL./~ al/e (!hare. <br />Person Responsible for the Gaming Operation, Induding Disbursement of Net Income <br />.;3/" ,e,,/J 78Ntf/6D <br />Business Address <br />tJS- 3tb. s+- St1u-fJ.-, <br />Mailing Address (if different) <br /> <br />State <br />ND <br /> <br />Business Phone Number <br />c9SJd. - SC;{;.;L <br />Zip Code <br />Sg~ <br />Zip Code <br /> <br />Stale <br /> <br /> <br />m e/-t?:e.. <br /> <br />Site Address <br />eA/,wdJ 1/ 1t7s 3,1-/:1. ,s-l-- ~ <br /> <br />S'ftr 11 Zip Code Coun~ A___, <br />Nv S2tJ!I ~, ________ <br />.. Poker, Twen'ty-one, and Paddlewheels may be Conducted only by a Charity L6Ca1 Pennil <br />DCalendar Raffle _ D Sports Pool D Poker' D Twenty-one' -. D Paddlewlieels' <br /> <br />Check the Game(s) to be Conducted: <br />_ D~ingo ~ffle <br /> <br />DESCRIPTION AND RETAIL VALUE OF PRIZES TO BE AWARDED <br /> <br />Game Type <br /> <br />Description of Prize <br /> <br />Retail Value of <br />Prize <br /> <br />Game Type <br /> <br />Description of Prize <br /> <br />Retail Value of <br />Prize <br /> <br /> <br />(Umit $12,000 per year) <br />Total: $ <br /> <br /> <br />a:~UIS~J~Og R;j;t:::_%k:!:~ ~ ~:kiZ;~ <br /> <br /> <br />Does the organization presently have a state gaming license? aJ.No 0 Yes . If '"Yes: the organization is not eligible for a local permit or charity local <br />permit and should call1he OffIce of Attorney General at 1-800-~9240. . <br /> <br />Has the organization received a charity local permit from this or another city or county for the fiscal year July 1 through June 3D? .Q?NO DYes _ If''Yes,. <br />the organization does not qualify for a local permit or charity local permit <br /> <br />Has the organization received a local pennit from this or another dty or county for the fiscal year Juiy 1 through June 30? ~o Dyes _ If "Yes,. <br />indicate the total value of all prizes previously awarded: S -. This amount is part of the total prize limit of $12,000 peryear. <br /> <br />Signature of Organization's Top Executive Ottidal <br />J~ <br /> <br /> <br /> <br />&uu~ <br /> <br />