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<br />MINNESOTA 2003 LICENSE RENEWAL NOTICE <br />CURRENCY EXCHANGE <br /> <br />The following information must be completed as part of the renewal application: <br /> <br />1. Attach to this form a list of the name(s), business and residence address, and official title of each director, officer, <br />limited or general partner, manager, shareholder holding more than ten percent of the outstanding stock of the <br />corporation, and employees with authority to exercise management or policy control over the company or member of <br />the licensee. The list should contain the equity ownership of each person. <br /> <br />2. Each person listed in item 1 must request the Bureau of Criminal Apprehension conduct a background investigation on <br />the form provided. Completed forms must be submitted with your renewal application. <br /> <br />3. Attach a current fee schedule of all fees charged by the currency exchange office for cashing checks, money orders <br />or travelers checks. The list must include the type of checks cashed, the fees charged, and whether or not the fees <br />vary depending on the amount of the check. <br /> <br />4. Attach the $10,000 Surety Bond (on the forms provided) with a power of attorney form. The bond must be effective <br />January 1, 2004, until December 31, 2004. <br /> <br />5. Does the licensee have employees at the currency exchange location? <br />[ X] Yes [ ] No If yes, you must provide evidence of current workers' compensation insurance. Attach a copy <br />of the certificate of insurance. <br /> <br />6. Does the licensee operate any other currency exchange locations? <br />[ X] Yes [ ] No If yes, attach to this form the name of the location, the street address, city, state, zip code, and <br />county. <br /> <br />7. <br /> David Caulfield District Manager Pawn America MN, L.L.C. <br /> Name Title Firm Name <br /> 181 River Ridge Circle S. Burnsville MN 55337 <br /> Street Address Cit State/Zi Code <br /> 952-646-1763 952-646-2763 <br /> Tele hone Number Fax Number E-mail address <br />8. Contact to consumer com laints: <br /> same as above <br /> Name Title i=irm Name <br /> Street Address Cii State/Zi Code <br /> Tele hone Number Fax Number E-mail address <br /> <br /> <br />9. <br /> <br />Contact person at the currency exchange location: <br />Nathan Ganges tad Head:: Coach <br />Name Title <br />1715 N. Rice Street I ~Roseville MN 55113 <br />~t'!",ac'+ t".-, !-4,,~lf'~f:,7~ f:' I c+_...../"'7:_ ,",_-I_ I <br /> <br />I Vt.l vC;l"UUI v~;:) <br /> <br /> <br />I 651-487-1595 <br />Tele hone Number <br /> <br />I (.ITV <br /> <br />i -'OJ <br />9S2-2T7-51OLJ, <br />Fax Number <br /> <br />I VIr"!I~!" 'f-' vn(l~ <br />I ---. -. -~- <br /> <br />E-mail address <br /> <br />Page 2 of 2 <br />