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MINNESOTA 2002 CURRENCY EXCHANGE LICENSE RENEWAL NOTICE The following information must be completed as part of the renewal application: 1. Attach to this form a list of the name(s), business and residence address, and official title of each director, officer, limited or general partner, manager, shareholder holding more than ten percent of the outstanding stock of the t., '__.- corporation, and- employees with authority to exerciSe management or policy control over the company or member of the licensee. The list should contain the equity ownership of each person. - 2. Each person listed In Item 1 must request the Bureau of Criminal Apprehension conduct a background investigation on the form provided. Completed forms must be submitted with your renewal application. Attach a current fee schedule of all fees charged by the currency exchange office for cashing checks. money orders or travelers checks. The list must include the type of checks cashed, the fees charged. and whether or not the fees vary depending on the amo~nt of the check. Attach the $10,000 Surety Bond (on the forms provided) with a power of attorney form. The bond must be effective ,January 1, 2003 until December 31, 2003. 3. 4. 5. D~} the licensee have employees at the currency exchange location? [ j\J Yes [ ] No If yes, you must provide evidence of current workers' compensation Insurance. Attach a copy of the certificate of insurance. 5. eo~ the licensee operate any other currency exchange locations? I X] Yes [ ] No If yes, attach to this form the name of the location. the street address, city, state, zip code and county. 7. issues: NamS hef"v"'" 0 Title Street Address 13'1 CD4 Fax Number q 8. Contact to consumer com laints: f (Vv;..(' Name Street Address ~y..,,=~ v. \\~ Tele hone Numbe~ ~r -4>zJ . Fax Number 9. Contact erson at the curren Firm Name Firm Name E-mail address - Title Street Address 13Cf lD<1 b Vi I'~ Tele hone Number SJ-KqS...l/Oz,1 Fax Number - Kqg- 2-2tY1 E-mail address , f; ~ ~ -