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Minnesota Lawful Gambling <br />Bingo Hall License Renewal Application - LG300 <br />License number: BH046 Name of applicant: Little Canada Market Place <br />Effective date: 2/1/2002 Expiration date. <br />1/31/2003 <br />Personnel: <br />The owner of the premises must be the lessor of the bingo hall. Subleases are not allowed. <br />• Verify that the personnel list below is complete and accurate, and contains all owners, officers, managers, <br />directors, supervisors, and persons or entities with a direct or indirect financial interest of five percent or more, <br />as prescribed by board rule. <br />• Add new personnel not listed and submit an LG315. <br />Name <br />Role Duties <br />Robert Edward Grootwassink Owner <br />Mark Allen Hotzler Owner <br />Oath <br />I declare that this application is correct and complete <br />to the best of my knowledge and belief. <br />I will familiarize myself with the laws of the state of <br />Minnesota and rules of the Board governing gambling <br />and agree, if licensed, to abide by those laws and <br />rules, including amendments to them. <br />I declare that I am qualified under the terms of <br />Minnesota Rules, part 7862.0010, subpart 3, to be <br />licensed as a bingo hall and will abide by the <br />restrictions set forth in Minnesota Rule, part <br />7862.0010, subpart 4. <br />et <br />I declare that any lease agreements between the <br />bingo hall licensee and lawful gambling organizations <br />will specifically identify any goods or services that the <br />organization is required to purchase from the lessor or <br />a third party vendor, and that all goods and services <br />furnished as a part of the lease agreement will be <br />valued at their fair market value. <br />Changes in the information submitted in this <br />application will be submitted in writing to the Board <br />and local unit of government within ten days after the <br />change occurs. , <br />Signature of chief executive officer <br />ire <br />Name (please print) <br />Date: <br />Mail Renewal Application to Gambling Control Board, with attachments. <br />LG300 - Bingo Hall License Renewal Application <br />LG302 - Bingo Hall Occasion List <br />LG315 - Bingo Hall Personnel Information <br />Resolution - Local unit of government approval <br />resolution (city or county); and <br />Check for $2,500 license fee payable to "State of <br />Minnesota'' (fees are considered earned and are not <br />prorated or transferrable) <br />Mail to: <br />Page 10 <br />Gambling Control Board <br />Suite 300 South <br />1711 West County Road B <br />Roseville, MN 55113 <br />