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Minnesota Lawful Gambling Bingo Hall License Renewal Application - LG300 Ucense Number: BH046 Name of Applicant: Little Canada Market Place Effective Date: 2/1/2001 Expiration Date: 1/31/2002 Personnel: Verify that the personnel list below is complete and accurate, and contains all owners, officers, managers, directors, supervisors, and persons or entities with a direct or indirect financial interest of five percent or more as prescribed by board rule. • The owner of the premises must be the lessor of the bingo hall. • Subleases are not allowed. • Owners, officers, directors, managers, supervisors, and persons or entities with a direct or indirect finandal interest of five percent or more must submit a separate Bingo Hall Personnel Information - LG315. • Add new personnel not listed and submit an LG315. Name Role Duties Robert Edward Grootwassink Owner Mark Allen Hotzler Owner Oath • 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 of Minnesota Rules, part 7862.0010, subpart 3, to be licensed as a bingo hall and will abide by the restrictions set forth in ▪ Minnesota Rules, part 7862.0010, subpart 4. • 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 fumished as a part of the lease agreement grill 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 change occurs. Date: Signature of the Bingo Hall CEO Attach and Mail ❑ LG300, Bingo Hall License Renewal Application ❑ LG302, Bingo Hall Occasion List ❑ LG315, Bingo Hall Personnel Information ❑ Local unit of government approval resolution (dty or county); and ❑ Check for 32,500 license fee payable to "State of Minnesota" (fees are considered earned and are not prorated or transferrable) Mail application and attachments to: Gambling Control Board Suite 300 South 1711 West County Road B Roseville, MN 55113 Page 6