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e <br />MINNESOTA 2004 LICENSE RENEWAL NOTICE <br />CURRENCY EXCHANGE <br />The following information must be completed as part of the renewal application: <br />i. 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 requestthe 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 $10,000 Surety Bond (on the forms provided) with a power of attorneyform. The bond must be effective <br />January 1,2005, until December 31,2005. <br />5. Does the licensee have employees at the currency exchange location? <br />[ I���� � ] No If yes, you must provide evidence of current workers' compensation insurance. Attach a copy <br />nf tF�$ cQrtif� t� �� +n��r�r��- <br />� Does the license operate any other currency exchange locations? <br />C ) Yes [�] No lf yes, attach to this form the name of the location, the street address, city. state, zip code, and <br />COUllty. r <br />' Contact person for <br />���� � <br />��� <br />relating to lic��+sln� Issu��: <br />����� <br />I�c��� .� �" ��r��1� �o{ b� � <br />� s�r�t ��� �'��r�� � <br />I������� ���� <br />'�el� one Number <br />'� -� - -- - - - - . . <br />��� ���� � <br />'�� �x ��� <br />���������� <br />1 �$� ���,�f -� ----- - <br />� Contact erson for uestions relatin to consumer <br />Name ��f �� � f1'�l/tl_ Ti�ie <br />Street Address <br />� Telephone Number � Fax Number <br />� Contact person at the currency exchange location: <br />Name ,.�C�r}�� � � ���.Trn� <br />Street Address <br />Teleahone Number <br />Fax Number <br />������ �.���� <br />I��� �� � ������� <br />��l ��� � � <br />�I� Cn�d� _ � <br />�` ����� <br />���� <br />F�r.zti r;flrra <br />C�de <br />Code <br />E-mail address <br />Page 2 of 2 <br />