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GFT,AT Sq~ <br />~r :~.....: i~ <br />`~~ ~ GAMING SITE AUTHORIZATION G - - - - ~- - -~- <br />y =• Site License Number <br />,~~~~~~~ OFFICE OF ATTORNEY GENERAL (Attorney General Use Only) <br />'~ x ~ . a° SFN 17996 (9-2005) <br />O~ NOYTN O <br />l l f <br />Ca 55 pun i 1 ~ I ` F-C , ~ [•( ~'j is hereby authorized to conduct games of <br />(Name of Or nization) <br />chance under the license granted by the Attorney General of the State of North Dakota . <br />at the following location: .~ ~U?l~ ~~ ~;-29-"ac~hc(S the address of which is: <br />(Street) (City) (Zip Code) (County) <br />Date(s) authorized: Beginning ~~ v..t / ~ v o 9 Ending ~~~ v 31 2 0 l o <br />Specific location of gaming withiri facility (required): ~ ct l 1 d.' <br />Number of twenty-one tables (required)(if zero, enter "0') __- _ ~- - -- <br />RESTRICTIONS: (to be completed ONLY if restrictions are set by the local governing body) <br />1. <br />2. <br />3. <br />Days of week of gaming operations _ <br />Hours of gaming <br />List each specific game type prohibited <br />Attorney General Date Signature of City/County Auditor Date <br />rn i chaP,Q Yr~'rel ~ 1Gti`~- ~( ~t.rS (~I,~,r>~t L~.;'~-~' <br />P NT Name /Official <br />INSTRUCTIONS: <br />1. City/County Auditors - Retain a copy of the Site Authorization for your files. ' <br />2. City/County Auditors -Return the original Site Authorization form to the Organization. <br />3. Organizations -Send the original, signed, Site Authorization to the Office of Attorney General with any <br />other applicable licensing forms for final approval. <br />RETURN -ALL. DOCUMENTS TO: <br />_- _ ___ <br />icensing_Section _ _ ____ ____ <br />- - - - -- <br />600 EBoulevard Ave, Dept. 125 <br />Bismarck, ND 58505-0040 <br />Telephone: 701-328-2329 OR 800-326-9240 <br />