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<br />E ALL applicants must answer the following questions. If any questions are answered "YES," you MUST <br />attach a detailed written explanation and any legal documentation, if applicable. <br />Have you, any of the owners, partners, officers, managers, directors, or shareholders owning more than 10010 of the <br />corporate stock: <br />YES NO <br />o ~ 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 vt 2. Been the subject of any inquiry or investigation by any division of the Minnesota Department <br />of Commerce? <br /> <br />o _ 3. 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 />o ~ 4. 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 violations, <br />in any State or Federal Court? <br /> <br />0 ~ 5. Been a defendant in any lawsuit involving claims of fraud, misrepresentation, conversion, <br /> mismanagement of funds or breach of contract? <br />0 ~ 6. 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 />0 O!l 7. Have any unclaimed property (unclaimed funds or property over 3 years old) to report under <br /> Minnesota Statutes, Section 345.37? <br />0 ~ 8. Filed for bankruptcy or protection from creditors or currently have outstanding unsatisfied <br /> judgment( s )? <br />0 li 9. Been affiliated with any other currency exchange? <br />0 a 10. Will the applicant sell lottery tickets at the licensed location? <br /> <br />I HEREBY CERTIFY THAT ALL INFORMATION CONTAINED IN THIS APPLICATION AND ANY <br />ACCOMPANYING DOCUMENTS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. <br />I CERTIFY THAT THIS DOCUMENT HAS NOT BEEN ALTERED OR CHANGED IN ANY MANNER <br />FROM THE FORM ADOPTED BY THE DEPARTMENT OF COMMERCE. <br />JII4~ 'I-d:;;.-D;( <br />. <br />Signature of Owner, Partner or Corporate Officer Date <br />e&O!<.-4E FA R J11 bO, f;~/~ J- <br />Print Name of Owner, Partner, or Corporate Officer <br /> <br />3 <br />