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Lawful Gamblin;: <br />Bingo Hall License Renewal Application = LG300 <br />License number: SH053 Name of applicant: capito �' Investments LLP <br />Effective date: 7/1/2003 Expiration date: <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 />d irectars, supervisors, and persons or entities with a direct or indirect firs andai interest of a ercen t or <br />� more, <br />as prescribed by board rule. <br />Add new personnel not listed and submit are LG315. <br />Name <br />Rule <br />Duties <br />Frank Michael Gaertner <br />Owner <br />Owner <br />John Richard, Gaertner <br />Owner <br />Owner- <br />Mary ,bane Miley <br />owner <br />owner <br />Yoshi Tani <br />owner <br />Owner <br />Oath <br />I declare that this application is correct and complete <br />to the best of my knowledge and belief. <br />1 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 Rules, part <br />7862.0010, subpart 4. <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 info rrnation submitted in this <br />application will be submitted in writing to the Board <br />and local unit of government within tern days after the <br />change occurs. <br />ez <br />Date: , R <br />nature of chief executive officer <br />7Z&,�k 9- - y <br />Name (please print) <br />Mail Renewal Application to Gambling Control Board, with attachments, <br />L3 00 - Bingo Hall License Renewal Application <br />L3 o2 - Bingo Hall occasion List <br />LG315 - Bingo Hail Personnel Information <br />Resolution - Local unit of government approval <br />resolution (city or county); and <br />Check fo��cens ee payable to "State of <br />Minnesota" (fees are con si Bred earned and are not <br />prorated or transferrable) 6 ' <br />fail to: <br />Gambling Control Board <br />Suite 300 South <br />1711 West County Road B <br />Roseville,, MINI 55113 <br />UU <br />