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BCA FORM — C:UR�NCY EXCHANGE <br />TO: Dep�trnent of Public Safely <br />B�a�eau of �l � <br />1?A6 Univ�sity A� <br />St Pavl, � 55104 <br />RE: Req�st for Backg�ound Check <br />C�re�c.y Ex�ange Liceaee (C� 53A) <br />I, _���� JQ�� I• � I� 11'1 � . date of birth ��� <br />i� �) <br />have made application to die Minnesota Dep�rrent of Commenx for a G�n+ency Ex�hange lic�se <br />under the pmvisioffi of Mi�o1a Statute chapter 53A <br />If I am not the applic�t fa� licensure I am either an officer, a limitodJgeneral parmer, a manager <br />or a s�lmreeholder and wip ovw oen peroent (10'/0) of ti� sbock. Or, I am an employee with the audwrity <br />to exercise manageirrent or poli�y control over me con�any. <br />I hereby �quest the Bu�eau of Criminal Ap�ensi� to conduct a be�ck�otmd inv�d� of <br />me for Gcensing purposes as required under Minnesota S�ute chapter 53A. <br />� <br />Si�une and Tide <br />RESIDENTIAL ADDRESS <br />� 5"G �' �c��rrN �,�j`, <br />��t%�rC� y� i��x <br />�,aci s s-� u� <br />C'IJRR�NCY EXCHANGE APPLICAN't This <br />_�'� —. <br />Date <br />SOCIAL SECURTTY NUMBER <br />� <br />�� <br />ze Minnesota <br />D�ment of Public Sa&ty, (�riminal Appm�i� PRIOR TO � to tlte Dep�t of <br />Comnie�+ce. There is a$15.00 fee faz esch backgc+�und check w��ch slwuld accompany this f�n. <br />Malae check paysble to the `9��tmeat of Pa61ic 3at�'. A self-�dd�r,ssed slac�od eavel�pe <br />must be inchided with t�is fomi vvhen submiuing the BCA nequest to t�,e Depar�ent of Public Safety. <br />1VOTE TO BiIREAU OF CRIMINAL APPBEHENSION: Please enclose completed <br />background Investigation in a sealed envelope along with this letter. <br />This form may be reproduced MN/DOC CE BCA FORM 7/1999 <br />