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<br />DCA FORM - CURRENCY EXCHANGE <br /> <br />TO: Department of Public Safety <br />Bureau of Criminal Apprehension <br />1246 University Avenue <br />St Paul, Minnesota 55104 <br /> <br />RE: Request for Background Check <br />Currency Exchange License (Chapter 53A) <br /> <br />I, {!;EORC;E T RRmh> . date of birth 03'L:92-/~~;z. <br />(Print Name) <br />have made application to the Minnesota Department of Commerce for a Currency Exchange license <br /> <br />under the provisions of Minnesota Statute chapter 53A <br /> <br />In am not the applicant for licensure I am either an officer, a limited/general partner, a manager <br />or a shareholder and will own ten percent (10010) of the stock. Or, I am an employee with the authority <br />to exercise management or policy control over the company. <br /> <br />I hereby request the Bureau of Criminal Apprehension to conduct a background investigation of <br />me for licensing purposes as required under Minnesota Statute chapter 53A. <br /> <br />/Ill!~~~) j~#(Eg/OE/V,1 <br />Signature and Title / <br /> <br />() "T -c';) -ac<!)2 <br />Date <br /> <br />RESIDENTIAL ADDRESS SOCIAL SECURITY NUMBER <br />c} 507' P&-ftf.&?J\/ P/fld)/ C <br />D.ROO/(Ly/V" /)hW~ <br />/Jf AI S-S--tl SL' ~ <br /> <br />CURRENCY EXCHANGE APPLICANT: This le Minnesota <br />Department of Public Safety, Criminal Apprehension PRIOR TO submission to the Department of <br />Commerce. There is a $15.00 fee for each background check which should accompany this form. <br />Make check payable to the "Department of Public Safety". A self-addressed stamped envelope <br />must be included with this form when submitting the BCA request to the Department of Public Safety. <br /> <br />NOTE TO BUREAU OF CRIMINAL APPREHENSION: Please enclose completed <br />background investigation in a sealed envelope along with this letter. <br /> <br />This form may be reproduced. <br /> <br />MN/DOC CE BCA FORM 7/1999 <br />