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E ALL applicants must answer the following questions. If any questions are answered "YES," yon MUS7 <br />attach a detailed written egplanation and any legal documentation, if applicable. <br />Have you, aay of the owneis, par�ners, officels, managers, directors, or shareholders owning more than 10°l0 of the <br />cotpotate stock <br />YES NO <br />c 1 �( l. Held a curnency exchange l�ense in any other state a�er than Minaesota? If YFS, ti�e new <br />license application must include a verificatian of license certified by the sta�(s); all other <br />applicants must verify that the cettification(s} previously submitted is ���• <br />0 1�( 2. Boen die subject of anY �1�Y � m��� b'Y �Y division of �e Minneso�a Departinent <br />of Commerce? <br />O � 3. Had any occupational license cens�ued, suspended, revoked, c�ncelled, t�rrr�inated or been <br />the subject of any type of admu�is�ive acaon in any stabe inctuding Minnesota? <br />0 � 4. Ha�e you ever been charged w�di, or convicted of, or been indicted for, or entered a plea to, <br />any criminal offense (felotry, gross misdetneanor or misdemeana), other than traffic violations, <br />in my State or Federal Court7 <br />a <br />0 <br />0 <br />0 <br />O <br />0 <br />� 5. Bcen a defendant in any lawsuit involving claims of fraud, misiept�esematioq convelsion, <br />mi�management of funds or b�'dCh of conttact? <br />lj� 6. Been notified by the Commissioner of Revenue, pursuant to Minnesota Statutes, Section <br />270A72, that you currently owe the State of Nlinnesota taxes? <br />� 7. Ha�e any unclaimed properly (unclaimed funds or property over 3 years old) to t+eport under <br />Minnesota Statutes, Section 345.37? <br />lj� 8. Filed for bankruptcy or protection from creditors or currently ha�e outstanding unsatisfied <br />l�as)? <br />1�( 9. Been affiliated with any other currency exchange? <br />� 10. Will the appliit sell lottery tickets at the licensed location? <br />I HEREBY CERTIFY THAT ALL INFORMATION CONTAlNED IN THIS APPLICATION AND ANY <br />ACCOMPANYING DOCUMENTS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. <br />I CERTIFY THAT THIS DOCUMENT HAS NOT BEEN ALTERED OR CHANGED IN ANY MANNER <br />FROM THE FORM ADOPTED BY TI� DEPARTNIENT OF CONIlVIERCE. <br />Signature of Owner, Partner or Corporate Officer <br />Print Name of Owner, Partner, or Coiporate <br />7 <br />��r �- <br />R3 <br />_aa _ �,�. <br />�� <br />