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<br /> <br /> <br /> <br /> <br />I, <br /> <br /> <br />date <br /> <br /> <br /> <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 />If I am not the applicant for licensure I am either an officer, a limited/general partner, a <br />manager or a shareholder and will own ten percent (10%) of the stock. Or, I am an employee with <br />the authority to exercise management or policy control over the company. <br /> <br />I hereby request the Bureau of Criminal Apprehension to conduct a background investigation <br />of me ,:or ~Ls required under Minnesota Statute Chapter 53A'y _! f', {! l' <br /> <br /> <br />Signature anti Titl( Bradley Kent Rixmann, Chief Manager Date I <br /> <br />RESIDENTIAL ADDRESS <br /> <br />SOCIAL SECURITY NUMBER <br /> <br />14488 Shady Beach Trail <br /> <br />470-94-3014 <br /> <br />Prior <br /> <br /> <br />CURRENCY EXCHANGE APPLICANT: This form must be completed by the 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 <br />Safety. <br /> <br />NOTE TO BUREAU OF CRljlfINAL APPREHENSION: Please enclose completed background <br />investigation in a sealed envelope along witlt tltis letter. <br /> <br />This form may be reproduced. <br /> <br />MN/DOC CE BCA FORM 512004 <br />