pf_03129 - Laserfiche WebLink

Home

FROM LEONARD. YES NO .. fg{ 0 STREET AND DEjNAF~) (WED) 1, 13' 99 17:28!~. 17:27/NO. 4260433848 t' j 4. Have you ever been charged with. or convicted of, or been indicted for, or entered a plea to, any criminal offense (felony, gross misdemeanor or misdemeanor). other thaI) traffic violatior'\s, in any State or Federal Court? LJ ~ 5. Been a defendant in any lawsuit involving claims of fraud. misrepresentation, conversion. mismanagement of funds or breach of contract? (] ~ 6. Been notified by the Commissioner of Revenue. pursuant to Minnesota Statutes. Section 270A.12. that you currently owe the State of Minnesota taxes? C1 ~ 7. Have any unclaimed property (unclaimed fundS or property over 3 years old) to report under Minnesota Statutes. Section 345.371 O}(3 8. Filoo for bankruptcy or protection from creditors or currently have outstanding unsatisfied judgment(s)? (] 'B 9. Been affiliated with any other currency exchange? I HEREBY CERTIFY THAT ALL INFORMATION CONTAINED IN THIS APPUCATION AND ANY ACCOMPANYING DOCUMENTS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I CERTIFY THAT THIS DOCUMENT HAS NOT BEEN ALTERED OR CHANGED IN ANY MANNER FROM THE FORM ADOPTED P D~:~NT OF COMMERCE. :,1::{/~,)" Lf- < "2 - 99 Signature of Owner, Pa~er or COrporate Officer ' Date ? PLEASE PROVIDE THE FOLLOWING INFORMATION ON AN ATT ACH~D SHEET: a All NEW applicants must provide a sIgned, notarized statement from the applicant stating the proposed location of the currency exchange is not located within 1/2 mile of another currency exchange. r:J A current fee schedule of all fees charged by your currency exchange office tor cashing checks, money orders or travelers> checks. The list MUST 1fIclude the type of check cashed, the fee that is charged, and Whether or not the fee varres depending on the amount of the check. o A list Including the name, date of birth, title, address and social security number for the following individuals: any owner, partner, officer, director, stockholder (owning 10% or more of the corporate stock), or any employee with the authority to exercise management or policy control over the company. a All IndMduals listed above must request that the Bureau of CriminaJ Apprehension conduct a bacKground Investigation on the form provided. Completed form(s) MUST be submitted with your license application. c:J The work experience covering ten (10) years prior to application for each person listed above. 1. INSTRUCTIONS To apply, complete (ple8se typfJ or print In ink) aod submit this form with the $300 fee 10 the Deparunent of Commerce, 133 East Seventh Street, St Paul, MN 55101. C1'Ieck or money order mU8t be payable to the 'MINNESOTA COMMERCE DEPARTMENT". WE CANNOT ACCEPT CASH. Incomplete forms will be returned to the business address listed, In order to become licensed, the applicant must provide the Commissloner of Commerce with a $10,000 bond (on the form included with this application). If applicant is a corporation, attach a copy of the Articles of Incorporation flied with the Secretary of Stat~. Applicants must also provide e Ii$t identifying the percentage of ownership for each officer and dIrector (including manager) and stockholder. If the applicant is a partnership, attach a copy of the Articles/Agreement of Partnership and a list identifying the percentage of ownership by each partner. The name under which the business will be conducted must be exactly the same as the name on your license. If operoting under any name other than the exact corporate or partnership name or, if an Individual proprielorahip doing business under any name other than your first and last name. attach a copy of the Assumed Name Cenlticate by the Minnesota Secretary of State (651) 296-2803. z. 3. 4. 5.