Filing Letter to Board in Response to M Bennett Email with Exhibits 12 02 2024

Page 11 PLEASE TYPE OR PRINT ALL INFORMATION STATE ASSIGNED LICENSE NUMBER 1802. 33. 005 _ (011 AFFIDAVIT LICENSE PERIOD APPLIED FOR From_97/01/2021 +, _ 06/30/2022 DATE: ) state of _ VIRGINIA ; ) ss: County ot FAIRFAX ; ) As provided by law (R.S. 33:1-35), (Check One) 4. The Individual Applicant 2. Members of the Partnership Applicant Mark Burnett, President of HGC Basking Ridge, LLC (President/Vice-President) (Corporation or Club Name) consent(s) that the licensed premises and all portions of the building constituting the licensed premises, including all rooms, cellars, closets, out-buildings, passageways, vaults, yards, attics and every part of the structure of which the licensed premises are a part and all buildings used in connection therewith which are in his/her/their possession or under his/her/their control, may be inspected and searched without warrant at all hours by the Director of the Division of Alcoholic Beverage Control, his or her duly authorized deputies, inspectors or investigators and all other sworn law enforcement officers, and being duly sworn according to law, upon his/her/their oath(s), depose(s) and say(s) that he/she is (they are) the person(s) duly authorized to sign the application, that in instance of corporate ownership, the signator is authorized by corporate resolution to sign on behalf of the corporations; and that the contents of this application represent complete disclosure of the fact, and that the contents of this application are true. 3. (Signature of Individual Agent / Sole Proprietor) (Corporations Only) Attestation by Corporate Secretary (Partnership Name) (Signature of Partner) HGC Basking Ridge, LLC Attest: Ma F (Signature of Partner) » MAC EO Secretary (Signature of Corporate President or Vice President) (Signature of Partner) signature Mark Burnett, President Affix Corporate Seal (Signature of Partner) Sworn to ant eens before me ENN lee <3 & 22 st &. this 4 day of Ker 20 > Huaneilis Gam Ranosy COMMISSION (Signature of OfficeSAdministering Oath) 7 AFFIDAVIT MUST BE SIGNED HERE —— NUMBER j = 7902323 BY DULY AUTHORIZED Komberly hun Roaavon NOTARY PUBLIC (Printed Name of Gfficer Administering Oath) an - 49, OR AN ATTORNEY-AT-LAW U\ 30\ TOEN sexgsaes? OF NEW JERSEY (Title of Officer Administering Oath) (Date of Expiration of Commission, if applicable)