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AUG. 31.2004 8:58AM GROOTWASSINK REAL ESTATE N0,779 P. 10 Return Complete Renewal Application By: 11/2/2004 Submit a check made • a • ble to the State of Minnesota for the • 000 license fee. Bingo Hall: Little Canada Market Place Business Address: 2900 N Rice St, Little Canada, MN, 55113 Phone: (651) 483-1203 Fax: Current License Expires: 1L31 /2005 Renewed License Terni: License #; BN046 Type: Limited Liability Company Business ID #: 2/2/2004 ka 1/31/2996 A separate personnel information form for each employee listed below is included with this application. All personnel forms must be signed by the applicant in the presence of a notary. Personnel forms are attachments to the bingo hall renewal application and must be .'S el at ,! ..; t. h- •in• hall fen- •i a,.h.: i. a! a ..•IA!.aS. Grootwassink, Robert Edward Hotzler, Mark Allen Duties: Duties: I declare that this application is correct and complete to the best of my knowledge and belief, I will familiarize myself with the laws of the state of Minnesota and rules of the Board governing gambling and agree, if licensed, to abide by those laws and rules, including amendments to them. I declare that I am qualified under the terms within Minnesota Rule, to be licensed as a bingo hall and will abide by the restrictions set forth in Minnesota Rule. I declare that any lease agreements between the bingo hall licensee and lawful gambling organizations will specifically identify any goods or services that the organization Is required to purchase from the lessor or a third party vendor, and that all goods and services furnished as a part of the lease agreement will be valued at their fair market value. Changes in the information submitted in this application will be submitted In writing to the Board and local unit of government within ten days after the .. nge occurs. Printed Name of Chief Executive Officer Signature of Chief Executive Office Date Signed rI xt - You must obtain and submit with the renewal application, a resolution of approval from the local unit of government (city or county) having jurisdiction over the bingo hall. Complete and submit the enclosed LG302 -Bingo Hall Occasion List Rotating Schedules must be provided in a dear legible format (i.e. calendar) for the entire license period, The information requested on this form will be used by the Gambling Control Board (Board) to determine your qualification to be Involved In lawful gambling aetla hes In Minnesota, and to assist the Board In conducting a background Investigation of you. You have a fight to refuse to supply the Inrotmadon requested; however, If you refuse t0 supply this IMOmlatlon, the Board may not be able to determine your quailfcatlon$ and, as a consequence, may refuse to register you. If you supply the Information requested, the Board will be able to register you. You are required to provide your Social Security number on this form. Your Social Secant/ number win be used to determine your compliance with the tax laws of Minnesota. Authorization for requiring your Social security number is found at 42 U.S.0 405 (c)(0. Your name and address will be public Information when received by the Board. All the other Information that you provide will be private data about you until the Board approves your registration. When the Board approves your registration, all of the Information that you have provided to the Beard In the process of registering will become public except For your Soda! Security number, which remains private. If the Board does not approve your reglsbabon, all the Information you have Platte data about you arse registering ilable only to tihe�Iawinwith eard gibers staf of the Board whose work assignment public requires that they have access to the Information; the Minnesota Department of Public safety; the MInnesota Atmrney General; the Minnesota Commissioners of Administration, Finance, and Revenue; the Minnesota i egislat va Auditor; national and International gambling regulatory agencies; anyone pursuant to court order; other indMduals and agencies that are specifically authorized by state or federal law to have access to the information; Individuals and agendes for which law or legal order authorbes a new use or sharing of Information after this notice was given; and anyone with your written consent. Obtain current GCB forms by visiting us at wowxgcbstate.mn.us Licensing Contact Rode Rolph Phone: (651)639 -4079 Fax #: (651)639-4073 E -Mail: State of Minnesota Gambling Control Board 1711 WCo Rd B #300 South Roseville, MN 55113 node. rol phegcb.state.mn.us Printed on: 2 Friday, July 30, 2004 Page 1 of J.