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(USE ADDITIONAL SHEETS IF NECESSSARY.) LICENSE NUMBER EXPIRATION DATE ANOKA COUNTY APPLICATION FOR PRECIOUS METAL DEALER LICENSE I (First, Middle, Last Name) as (Owner, Partner or Officer) for and in behalf of (if individual, give full name; if partnership give name of all partners; if a corporation, give true corporation name.) hereby make application pursuant to the provisions of Minnesota Statutes, Chapter 325F, for a license to engage in or transact business as a Precious Metal Dealer in Anoka County. Applicant’s Resident Address: Applicant’s Date of Birth: Business Name: Principal Business Address: Name of Owner of Principal Business: Date of Birth: Resident Address of Owner: Name of Manager/Proprietor of Principal Business: Date of Birth: Resident Address of Manager/Proprietor: OTHER BUSINESS LOCATIONS WITHIN ANOKA COUNTY: (EACH BRANCH OFFICE SHALL BE OPERATED UNDER THE SAME NAME AS THE PRINCIPAL OFFICE.) 1. Branch Office Address Name of Owner of Business (If different from Principal Business) Date of Birth Resident Address of Owner Name of Manager/Proprietor of Business Date of Birth Resident Address of Manager/Proprietor ---PAGE BREAK--- (USE ADDITIONAL SHEETS IF NECESSSARY.) If applicant is a partnership or corporation, list name, positions/title, date of birth and phone number of all individuals: NAME POSITION RESIDENT ADDRESS PHONE DATE OF BIRTH I swear or affirm under oath, under penalties of perjury, that all statements made in the above application are true and correct. Date Signature Subscribed and sworn to before me this day of , 20 . Signature of Notary Public (seal)