Date:

    COLLECTOR LICENSE CERTIFICATION

    I hereby make application for a Minnesota Individual Collector License, and I state, under oath and under penalty of perjury, that each of the following statements is true:

    1. My true and correct name is:
    2. Within five (5) years from the date above, I have not been charged with committing a felony.
    3. Within the past five years, I have not been convicted of fraud or a felony.
    4. I have never had a judgment entered against me, in any court, for failure to account to any client or customer for money collected for them or on their behalf.

    Each of the above statements is true and correct.

    (Signed)