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BCA FORM — CURRENCY EXCHANGE <br />TO: Department of Public Safety <br />Minnesota Bureau o f Criminal Apprehension <br />Atm: CJIS-Criminal History Access <br />1430 Maryland Avenue East <br />St. Paul, Minnesota 55106 <br />(651) 793-2400 <br />RE: Request for Background Check <br />Currency Exchange License (Chapter 53A) <br />I, Rrarllev Kent Rixmann , date ofbirth� , <br />(Print Name) <br />have made application to the Minnesota Department of Commerce for a Currency Exchange license <br />under the provisions of Minnesota Statute Chapter 53A. <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 />I hereby request the Bureau of Criminal Apprehension to conduct a background investigation <br />��f m� foE E:c�i�+� ur�x�s�s required under Minnesota Statute Chapter 53A. <br />. � � �� <br />� ' �"f�-G7} <br />. __._ .. �, � <br />Signature �nii Tit�� Bradley Kent RiYmann, Chief Manager �$�� <br />RESIDENTIAL ADDRESS SOCIAL SECURITY NUIVIBER <br />14488 Shady Beach Trail <br />Prior Lake, MN 55372 <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 />NOTE TO BUREAU OF CRI1l�INAL APPREHENSION: Please enclose completed background <br />investigation in a sealed envelope along with this letter <br />This for�n may be reproduced. MN/DOC CE BCA FORM 512004 <br />