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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 afficial title of each director, officer, <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 contrat over the company or member of <br />the licensee. The list should contain the equity ownership of each person. <br />r <br />2. 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 submittedwith your renewal application. <br />�, Attach a current fee schedule of all fees charged by the currency exchange office for cashing checks, money orders <br />or travelers chedcs. 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 $10,000 Surety Bond (on the forms provided) with a power of attomey fosrr�. The bond must be effecctivve <br />January 1, 2005, until December31.2005. <br />5. Qoes the licensee have employees at the currency exchange location? <br />�Yes [ ] No If yes, you must provide evidence of current workers' compensation insurance. Attach a copy <br />#{ie certificate of insurance. <br />�. �F� licensee operate any other currency exchange locations? <br />� Y�s �� No If yes, attach to this form the name of the location, the street address, city, state, zip code, and <br />a� <br />� <br />� Contact person for questions relating to licensin issues: <br />� � � -- — <br />N�me � � <br />i ���a �, �jr�., d ��C+ti� <br />��e+L +4ddre�� r r+ '.1ti� �'++,� � <br />� no�a N�n,,b�r ' �-�'1 � '�� F�c Nw�,�er� <br />�. Contact person for questions relatina to consumercomp <br />Name � <br />��� „ f� <br />Street Address � �i� <br />� <br />Tele hone Number <br />9 Contact erson at the curr excY <br />Name ' <br />_ � �}. <br />�_ ���i' � �� <br />Street Address �� <br />Number <br />Title <br />location: <br />Ti�e <br />Fax Number <br />� <br />�' Fvrn �+larr� = <br />; � h ��{�1 �O[ <br />-$`� � � �' a ��„� <br />Code <br />Code <br />E-mail address <br />�{1 <br />� <br />'��. �.��� <br />� <br />Page 2 of 2 <br />