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<br />E. ALL applicants must answer the following questions. If any questions are answered "YES," you <br />MUST attach a detailed written explanation and any legal documentation, if applicable. <br /> <br />Have you, any of the owners, partners, officers, managers, directors, or shareholders owning more than <br />10% of the corporate stock: <br /> <br />YES NO <br /> <br />CJ Iii 1. Held a currency exchange license in any other state other than Minnesota? <br />If YES, the new license application must include a verification of license certified by the <br />state(s); all other applicants must verify that the certification(s) previously submitted is accurate. <br /> <br />CJ 6a 2. Been the subject of any inquiry or investigation by any division of the Minnesota Commerce <br />Department? <br /> <br />CJ 53 3. Had any occupational license censured. suspended, revoked, cancelled, terminated or been <br />:... <br />the subject of any type of administrative action in any state including Minnesota? <br /> <br />f] CJ 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 <br />violations, in any State or Federal Court? <br /> <br />CJ 6i 5. Been a defendant in any lawsuit involving claims of fraud, misrepresentation, conversion, <br />mismanagement of funds or breach of contract? <br /> <br />CJ m 6. Been notified by the Commissioner of Revenue, pursuant to Minnesota Statutes, Section <br />270A. 72, that you currently owe the State of Minnesota taxes? <br /> <br />CJ 13 7. Have any unclaimed property (unclaimed funds or property over 3 years old) to report under <br />Minnesota Statutes, Section 345.37? <br /> <br />CJ ~ 8. Filed for bankruptcy or protection from creditors or currently have outstanding unsatisfied <br />judgment(s)? <br /> <br />s CJ 9. Been affiliated with any other currency exchange? <br /> <br />C1 oa 10. Will the applicant sell lottery tickets at the licensed location? <br /> <br />I HEREBY CERTIFY THAT ALL INFORMATION CONTAINED IN THIS APPLICATION AND ANY <br />ACCOMPANYING DOCUMENTS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. <br /> <br />I CERTIFY THAT THIS DOCUMENT HAS NOT BEEN ALTERED OR CHANGED IN ANY MANNER FROM <br />THE FORM AD B E DEPARTMENT OF COMMERCE. <br /> <br /> <br /> <br />Bradley K. Rixma.nn <br />Print Name of Owner, Partner, or Corporate Officer <br />rev 7/99 <br /> <br />3 <br />