Prec Metals Dealers App

APPLICATION FOR PRECIOUS METAL DEALER’S LICENSE
License No.________________
License Expires: _____________
License Fee: ______$50.00________
County of Hennepin
DIRECTOR OF LICENSING
Hennepin County Government Center
300 South 6th Street – Suite A025
Minneapolis, Minnesota 55487-0026

Owner
I _________________________________________________ as_______________________________
First
Middle
Last
Owner or Officer
for and in behalf of ____________________________________________________________________
Company’s Name
__________________________________________________________________
Company’s Address
_________________________________________________________________
City
State
Zip
Telephone Number(xxx-xxx-xxxx)_________________________ Fax Number(xxx-xxx-xxxx)__________________
hereby make application pursuant to the provisions of Minnesota Statute, Chapter 325F, for a license to engage in or
transact business as a Precious Metal Dealer in Hennepin County.
Applicant’s Resident Address___________________________________________________________
______________________________________________________
City
State
Zip
Telephone Number ______________________________________
Applicant’s Date of Birth(mm/dd/yyyy) _________________________________
Is this application a renewal?

Yes

No

If so, expiration date(mm/dd/yyyy) _______________

EACH BRANCH OFFICE SHALL BE OPERATED UNDER THE SAME NAME AS THE PRINCIPAL OFFICE.
PLEASE ATTACH A LIST OF ADDRESSES OF OTHER BUSINESS LOCATIONS WITHIN HENNEPIN
COUNTY IF THIS APPLIES TO YOU.
PARTNERSHIPS OR CORPORATIONS REQUIRE A LIST OF ALL OFFICERS OF THE COMPANY
INCLUDING THEIR ADDRESSES, TELEPHONE NUMBERS AND DATES OF BIRTH. PLEASE ATTACH A
LIST IF THIS APPLIES TO YOU.
I swear or affirm under oath, under penalties of perjury, that all statements made in the above application are true
and correct:
______________________________
Application Date
Subscribed and sworn to before me
this ____ day of_________, 20___.
By__________________________
Notary

Clear Form
Print Form
__________________________________
Applicant's Signature

HC1159(3/10)