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<br />STATE OF MINNESOTA <br />DEPARTMENT OF COMMERCE <br />DIVISION OF FINANCIAL EXAMINATIONS <br />85 EAST 7TH PLACE, SUITE 500 <br />ST. PAUL, MINNESOTA 55101-2198 <br />(651) 282-9855 <br /> <br />OFFICE USE ONLY <br />Deputy <br />Asst. <br />Chief <br />Review <br />Data Entry <br />Currency Exchange <br /> <br />CASHIER USE ONLY <br /> <br />JUN 2 0 290~ <br />Y\I"\ \ \ <br />Rac'd$~ <br /> <br />Surety Bond Number <br />55 <br />CURRENCY EXCHANGE Insurance Company NAIC Number c2. 7~1 <( <br />LICENSE APPLICATION Nor+A. ~ iCc.l/'......_ 5 ~c' L. c., <br />The data, which you furnish on this form, will be used by the Department of Commerce to assess your qualifications for <br />a license. Disclosure of your social security number is voluntaIy. You are not legally required to provide this data; <br />however, if you do not provide your social security number, the Department of Commerce may be unable to gmnt a <br />license. The Department may use social security numbers for revenue recapture as authorized by Minnesota Statutes, <br />Chapter 270A and for identification purposes. After issuance of a license, all information contained in this application, <br />except your social security number, is public pursuant to Minnesota Statutes, Chapter 13. <br /> <br /> <br />License Number <br /> <br />Processing Date <br /> <br /> <br /> <br /> <br />~NEW <br /> <br />LJ RENEWAL <br /> <br />LJ AMENDED LICENSE <br /> <br /> <br />Check one: l] SOLE PROPRIETORSHIP <br />Ll PARTNERSHIP <br />R CORPORATION <br /> <br />stl/-- <br />COUNTY <br />/-1 t:::: HAlE P I A.I <br />STATE TAX 10 NUMBER <br />5. 6/ <br />E-MAIL ADDRESS <br />. rt3 bo ~) crf/l>/ L 71r) <br />Ll ASSOCIATION <br />Ll LIMITED LIABILITY PARTNERSHIP <br />Ll LIMITED LIABILITY COMPANY <br /> <br /> <br /> <br /> <br />t5/?lJO/(LY/,/ PA: )lENNEp/N <br />Place of Inco ration Coun <br /> <br />/1IN <br />State <br /> <br />9/1212001 <br /> <br />I MN/DOC CURRENCY EXCHANGE APPL 7/1999 <br />