Laserfiche WebLink
� <br />r� iNid�,���.� ���� L����I�E � � � �����1 �l��#� � <br />.. . �I�R1��NC`� ���N�N�E <br />The following information must be completed as part of the renewal application: <br />1. Attach to this form a list of the name(s}F 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 ownershipof each person. <br />�. Each person listed in item 1 must requestthe Bureau of CriminalApprehensionconduct a backgroundinvestigationon <br />the form provided. Completed forms must be submitted with your renewal application. <br />3. Attach a current fee schedule of all fees charged by the currency exchange office for cashing checks, mo�iey 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 />�. Attach the $10,000 Surety Bond (on the forms provided) with a power of attorneyform. The bond mustbe effective <br />January 1,2007, until December31,2007. <br />5, Does the licensee have employees at the currency exchange location? <br />[X � Yes � � No Ifiyes, you must provide evidence of current workers' compensation insurance. Attach a copy <br />of the certificate of insurance. <br />G. Does the licensee operate any other currencyexchange locations? <br />� K� Yes �� No lf yes, attach to this form the name of the location, the street address, city, state, zip code, and <br />co u nty. <br />?, Contact person for questions <br />David Caulfield <br />Name <br />181 River Ridge Circle S. <br />952-646-1763 <br />Telephone Number <br />to licensina issues: <br />D i s tri c t Manager <br />Tifle <br />Burnsville <br />952-646-2763 <br />Fax Number <br />R. Contact person for auestions relatina to consumer com <br />same a s above <br />Name <br />Street Add ress <br />� TelepE�one Number <br />�, Contact erson at the currenc <br />Paul Hess <br />Name <br />1715 N. Rice Street <br />Street Add ress <br />651-487-1595 <br />Te!ephone Number <br />Title <br />Fax Number <br />location: <br />Manager <br />Title <br />Roseville <br />j ��aj� <br />952-277-5104 <br />� Fax Number <br />Pawn America M�1, L.L.C. <br />Firm Name <br />1`'�N 55337 <br />e/Zit� Code <br />dave. caulf �eld@pawr�ame�ic< <br />E-mail address <br />Firm Name <br />Code <br />E-maii address <br />: �i 55113 ; <br />_l �ts�af�p ��� _ _� <br />1 E-mail address <br />Page 2 of 2 <br />