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MINNESOTA 2005 LICENSE RENEWAL NOTICE <br />CURRENCY EXCHANGE <br />The following information must be completed as part of the xe�ewa� application: <br />Attach to this form a list of the r�ame(s), business and residence address, and official title of each director, ofFcer, <br />limited or general partner, manager, shareholderholding 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 ownership of each person. <br />Each person listed in item 1 must request the Bureau of Criminal Apprehension conduct a background investigation on <br />the form provided. Completed forms must be submitted with your renewal application. <br />�_ Attach a current fee schedule of a!t fees charged by the currency exchange office for cashing checks, money 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 $10,000 Surety Bond (on the forms provided) with a powerof attorney form. The bond must be effective <br />January 1,2006, until December 31,2006. <br />�_ Da� .� licensee have employees at the cu� renc� exchange location? <br />� Yes [ ] No ff yes, you must provide evidence of current workers' compensation insurance. Attach a copy <br />Q ��� �$rtTff�a�� of insurance. <br />� <br />Does the licensee operate any other currency exchange locations? <br />c� Yes [� No If yes, attach to this form the name of the location, the street address, city, state, zip code, and <br />ounty. <br />Can�,.� ��.�s�n f� ues�ion� relaiin 6� lic�ns�n lss�es; _ — <br />� <br />-����� �- ���� � �� ��� <br />}i <br />� N�m� C TI�I�— — — <br />��� �� �� � � �- �� ������ - -....: <br />�r Addr�, s� .. _ . � Ci�yr <br />f��� ���� ��� f�� � �� � ��� <br />. T�lepil�n� �v�ial�er _ _ Fax N�mt�er <br />�. Contact erson for <br />Name � <br />� Street Address <br />ons relatina to consumer complaints: <br />,��,��_ Title <br />� Telephone Number <br />�_ Contact erson at the cu <br />Name ��s��� � <br />Street Address <br />Telephone Number <br />Fax Number <br />location: <br />Title <br />Fax Number <br />}��� ' �� <br />�' �' +�� �? <br />�� �� �� � <br />���'�`��f� �'�r �zs�c�-�� <br />L--,riall a�dr�ess ' <br />Firm Name <br />Code <br />E-mail address <br />Code <br />E-mail address <br />Page 2 of 2 <br />