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<br />" . <br />\ <br />" <br />j <br />J E. ALL applicants must answer the following questions. If any questions are answered "YES," you <br />MUST ~itach 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 10% <br />of the corporate stock: <br /> <br />YES NO <br />o 'cs 1. Held a currency exchange license in any other state other than Minnesota? If YES, the new <br />license application must include a verification of license certified by the state(s); all other <br />applicants must verify that the certification(s) previously submitted is accurate. . <br /> <br />o <br /> <br />'S"2. <br /> <br />o <br /> <br />t\-- 3. <br /> <br />o <br /> <br />..p- 4. <br /> <br />0 ~ 5. <br />0 ~6. <br />0 ~7. <br />0 ~/8. <br /> <br />Been the subject of any inquiry or investigation by any division of the Minnesota <br />Department of Commerce? <br /> <br />Had any occupational license censured, suspended, revoked, cancelled, terminated or been <br />the subject of any type of administrative action in any state including Minnesota? <br /> <br />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 />Been a defendant in any lawsuit involving claims of fraud, misrepresentation, conversion, <br />mismanagement of funds or breach of contract? <br /> <br />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 />Have any unclaimed property (unclaimed funds or property over 3 years old) to report under <br />Minnesota Statutes, Section 345.37? <br /> <br />Filed for bankruptcy or protection from creditors or currently have outstanding unsatisfied <br />judgment(s)? <br /> <br />o t3= 9. Been affiliated with any other currency exchange? ex~pt j( 0 +~ fVI(i;ofe{ Kdw.~ 5 <br /> <br />o f!( 10. Will the applicant sell lottery tickets at the licensed location? <br /> <br />I HEREBY CERTIFY THAT ALL INFORMATION CONTAINED IN TIllS APPliCATION AND ANY <br />ACCOMPANYING DOCUMENTS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. <br /> <br />I CERTIFY THAT TIllS, DOCUMENT HAS_NOT BEEN_ALTERED. OR CHANGED IN ANY MANNER <br />FROM THE FORM ADOPTED BY THE DEPARTMENT OF COMMERCE. <br /> <br />.~ vr ' <br />Signatufe of Owner, Partner or Corporate Officer <br /> <br />fVlA'R ~ Av..s -t.'-.,.) .s-M t i k <br />Print Name of O~ner, Partner, or Corporate Officer <br /> <br />-~vl\R.. 1'1 0 I <br />" <br /> <br />I?ate <br /> <br />... ;-~.- ..,: .~~~ <br /> <br />3 <br />