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<br />FROM LEONARD, STREET'AND DEINARD
<br />YES NO
<br />'SJC a
<br />
<br />(WEDJ 1. 13' 99 17: 28/8T. 17: niNO. 4260433848 P 3
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<br />4. Have,You ever been charged with, or convicted of, or been indicted for, or entered a plea to,
<br />any criminal offense (felony. gross misdemeanor or misdemeanor), other than traffic violations, in
<br />any State or Federal Court?
<br />
<br />.: . ~.~ .
<br />
<br />...~.
<br />
<br />[1 # 5.
<br />a 'tJ 6.
<br />0 JEJ 7.
<br />0 J(3' 8. '
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<br />Been a defendant in any lawsuIt invoJvingcJaims of fraud. misrepresentation, conversion,'
<br />mismanagement of funds or breach of contract? ,
<br />
<br />Been notified by the Commissioner of Revenue, pursuant to Minnesata Statutes. Section 270A.72, that
<br />you currently owe the State of Minnesota taxes?
<br />
<br />Have any unclaimed property (unclaimed funds or property over 3 yearS old) to report under Minnesota
<br />Statutes, Section 345.371 "
<br />
<br />Filed for bankruptcy or protectJon from creditors or currently have outstanding unsatisfied judgment(s)? ,
<br />
<br />. . ..,.
<br />
<br />'0 ~ ,9. Been affiliated with any other currency exchange?
<br />I HEREBY CERTIFY THATAU.INFORMATJON CONTAINED IN THIS APPUCATION AND ANY ACCOMPANYING
<br />, OOCUMENTS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
<br />I CERTIFY THAT THIS DocuMENT HAS NOT BEEN ALTERED OR CHANGED IN ANY MANNER FROM THE FORM
<br />ADOPTEDB~D.,E;A"~OFCOMMERCE, , .".' ,.' ,'., ,
<br />,~~7 " ,',' ,q--2."2- 99 '
<br />Signature of Owner, Partner or COrporate Officer , ' , Date, '
<br />, , ',' PLEASE P~V1DE THE FOLLOWING INFORMATION ON AN ATTACHED SHEET:
<br />
<br />". .
<br />o AIr NEWappticants must provide a signed. notarized statement from the applicant stating the proposed location of
<br />the currency exchange is not located within 1/2 mile of another curreney exchange., '
<br />Cl A current fee schedule of all fees charged by your currency exchange office for cashIng checks, money orders or
<br />travelers' checks. The list MUST include the type of check cashed, the fse that i$ charged, and whether or not the '
<br />'fee varies depending on the amount of the check. '
<br />IJ A list Including ,the name. date of birth, title, address and social security number for the following individuals: any
<br />owner, partner, officer, director, 'stockholder (owning 10% or more of the corporate stock), or any employee with the
<br />" authority to exercise management or policy control over the company.
<br />o All JndividuaJs listed above must request that the Bureau of Criminal Apprehension conduct a background
<br />fnvEt$tigatfon on the form provided. "Completed forrn(s) MUST be submitted with your license application.
<br />'C TheWOr1< experience covering ten (10) years prior to application for each person liSted above.
<br />
<br />, ' " , ,INSTRUCTIONS , '
<br />1. To apply, complete (pleas. /ypfJ or print In ink) end submit this fonn with the $300 fee 10 the, Department 01 Commerce, 133
<br />East SevenU'l Street, Sl Paul, MN 55101- Check or money order must be payable to the "MINNESOTA COMMERCE
<br />DEPARTMENT". WE CANNOT ACCEP'T CASH. Incomplete forms will be returned to the business address listed.
<br />2. In order to become licensed. the applicant must provide the Commissioner of Commerce with a $10,000 bond (on the form
<br />included with this appllc:atfon}. '
<br />3. If applicant Is a corporation, attach a copy of the Articles of Incorporai!nn filed with the Secretary of State. Applicants must also
<br />provide a Ii$t identifying the percentage of ownership for each officer and director (inducfmg manager) and stockholder.
<br />4. If the applicant is a partnership, attach a copy of the ArticleslAgreem ent , of Partnership aM a list identifying the percentage of
<br />ownership by each partner, '
<br />5. The name under which the business, will be conducted must be exacUy the same as the name on your license. If operating
<br />under any name other than the exact corporate or partnershIp name or, if an Individual propriefot'3hip doing bUSiness under any
<br />name other than your first and IaStname. attach a copy of the Assumed Name Certificate by the Minnesota Secretary of State
<br />, (651) 296-2803.
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