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MINNESOTA 2004 LICENSE RENEWAL NOTICE <br />CURRENCY EXCHANGE <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), 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 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 />3 Attach a current fee schedule of all 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 power of attomey form. The bond must be effective <br />January 1,2005, until December 31,2005. <br />� Does the licensee have employees at the currency exchange location? <br />[}� ] Yes [ ] No If yes, you must provide evidence of current workers' compensation insurance. Attach a copy <br />of the certificate of Insurance. <br />6. Does the licensee operate any other currency exchange locations? <br />[�] Yes [] No If yes, attach to this form the name of the location, the street address, city, state, zip code, and <br />county. <br />� Contact person for <br />David Caulfield <br />Name <br />s relatinq to licensinq issues: <br />District Manager <br />Title <br />181 River Ridge Circle S. Burnsville <br />Street Address r.�t�� <br />952-646-1763 952-646-2763 <br />, Telephone Number Fax Number <br />� Contact person for questions relating to consumer complaints: <br />Naame as above <br />me <br />Street Address <br />Title <br />� Telephone Number � Fax Number <br />�. Contact person at the currency exchange location: <br />Paul Hess Head Coach <br />Name Title <br />1715 N. Rice Street <br />Street Address <br />� ���� � -�� �- � 5� 5 <br />rel�Rl�r� hdumh�er <br />Roseville <br />952-277-5104 <br />Fax Number <br />Pawn America MDT, L.L.C. <br />Firm Name <br />E-mail address <br />Firm Name <br />State2ip Code <br />E-mail address <br />Mi <br />E-mail address <br />55337 <br />55113 <br />Page 2 of 2 <br />