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<br />FR[ThfU.UNJ\lilJ , <br /> <br />IJ 1 hH! NW 1Jt.1 N1UW , <br />'~, <br /> <br />lVH.UJ 1. J:i ')., i 1'; Lli.:J L 11; LUfJ'V. '1LVV'1.J.J 1.1 V , <br />) <br /> <br />.J <br /> <br />.~ .. " <br /> <br />. ~ <br /> <br />" <br /> <br />SCA FORM. CURRENCY EXCHANGES <br /> <br />TO: Departtnent of PubUc Safety <br />Bureau of Criminal Apprehension <br />1246 U'niversity AV,enue <br />St. Paul, Minnesota 55104 <br /> <br />RE: Request for Bac)(ground Check <br />CUrrency Exchange Ucens8 (Chapter 53A) <br /> <br />I. Steven J. Caulfield <br />(Print Name) <br /> <br />apprlCation to the Minnesota Departn'ient of Commerce for a CUrrency Excharlge license under the <br /> <br />. date of birth 10-10-62 <br /> <br />. have made <br /> <br />provisions of MiMe&ota Statute chapter 53A. <br /> <br />, , <br />It I am nofthe applicant for licerl$ure f am either aI'I officer. a limited/general partner, a manager <br />or a shareholder and wiIJ oWn ten percent (10%) cf the ~ock. Or, J am an employee with the a~ority to <br /> <br />exercise management or ~Iicy control over the company. ' <br />I hereby request the Bureau of Criminal Apprehension to conduct a baCkground investigation of <br /> <br />- me for ncensing purposes as re . <br /> <br />~ <br /> <br />, <br /> <br /> <br />under Mimesota Statute chapter 53A. <br /> <br />District Manager <br /> <br />1lm~'~:1~99 <br /> <br />Date <br /> <br />RESIDENTiAL ADDRESS <br /> <br />22831 Winteroreen St..N.W. <br />, Bethel, MN 55005, <br /> <br />SOCIAL SECURfTY NUMBER <br />501-92-2773 <br /> <br />~ . <br />~ . <br />· JANET K NICHOLS <br />'.NOTARY pUBlic - MINNESOTA , <br />HENNEPIN COUNTY <br />My~~res_~8~. <br />CURRENCY EXCHANGE APPLICANT This form must b~'ihE,Minnesota' Department of <br />PubUc Safety, Criminal ApprehensionPRJOR TO submission to the Department Of Commerce. There is <br />an sa.OO fee for each background check which should accompany this form. Make check payable to the <br />Department of Public Safety. ' <br /> <br /> <br />NOTE TO BUREAU OF CRIMINAL APPREHENSION: PINSB enclose completed backgl'Dund <br />inlltJ$liglltit:ln In 6 sealed enVBlope along with thi$/etter. <br /> <br />REV. &"95 <br /> <br />This form may be ~pfCJduC8d. <br />