pf_03535 - Laserfiche WebLink

Home

MINNESOTA 2003 liCENSE RENEWAL NOTICE CURRENCY EXCHANGE The follo\,8/in9 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 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. 3. Attach a current fee scheduie 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 amount of the check. 4. Attach the $10,000 Surety Bond (on the forms provided) with a power of attorney form. The bond must be effective January 1, 2004, until December 31,2004. 5. Does the licensee have employees at the currency exchange location? L.xJ Yes.. [ ]No If yes, you must provide evidence of current workers' compensation insurance. Attach a copy O'f the certificate of insurance. 6. Does the licensee operate any other currency exchange locations? [;><] Yes [ ] No If yes, attach to this form the name of the location, the street address, city, state, zip code, and county. 7. Contact uestions relatin . r1\ , Name ~he r' V Chf" I () i 2:,"'1 !.a Gj br.c;..... d Street Address ,!\v.LI'>i' Title ~ \1(: <;", de ;-'"' of Firm Name I Clt .1ti.Air n ~ ,,', t I <if StatelZip Code 3 Tele hone Number 5~-<?q~~CD i FaxNumberq5~- :'1-"220. E-mail address 8. Contact Derson for uestions relatin to consumer comolaints: /'"it "....--..., Name ~ her F'j t~l)(] r2L\ r~ () 'Title .yO~ bd:} ll') i ., I}) Street Address l q 11/1 L;(OnJ !~~~. Cit',-9L'd" h ~ \11 n,f' StatelZin Code Tale ,hone Number 99- fflf -iif; 21 Fax Number e9 - Wf-?2'f I E-mail address Firm Name J?'7(jjlL'" X{}7tiJI5.}", v f) }.c- ,c";r'7 . ;n /'1 0v~..j ,--,\4 rr- i ' ;;J OrlXl' '~l Name, erson at the currenc\ exchange location: I ..~,~ (' ".to.. \. T!~~e ,'if ( Jtl (~\lv... (/1 11 9. Contact i . I Street ;A.dGress I Teleohone Number ~r E-mail adores;;; State/Zio Code Page 2 of 2