FORM SA (To be left blank by all Applicants) Name _________________________________ Location ______________________________ Classification ___________________________ License No. _____________________________ Date Issued _____________________________ License Fee Received _____________________ Investigation Fee Received _________________ (To be filled in by all Applicants) APPLICATION FOR LICENSE PURSUANT TO THE SALE OF CHECKS ACT To: Alabama Securities Commission 770 Washington Street, Suite 570 Montgomery, AL 36130-4700 Date _______________________ The undersigned hereby makes application for a license under the provisions of the Sale of Checks Act. Ala. Code Section 8-7-1. et. al. to engage in the business of selling, issuing or otherwise dispensing checks, drafts, money orders or other instruments for the transmission or payment of money and/or the business of receiving money as agent for obligors for the purpose of paying such obligors’ bills, invoices or accounts in the State of Alabama. For the purpose of such application, the undersigned submits the following information: 1. (a) The full name of the Applicant is __________________________________________________ (b) The Applicant is a ______________________________________________________________ (Proprietorship, Corporation, Individual, Partnership, Joint Stock Association, Limited Liability Corporation) (c) If the Applicant is a corporation, the state of incorporation is ____________________________ Is Corporation qualified to do business in the State of Alabama? YES _____ NO _____ 2. The address of the Applicant’s principal office in the State of Alabama is: (street) 3. (county) (state) (zip) If the Applicant is a foreign corporation, the address of the principal office of the corporation is: (street) 4. (city) (city) (county) (state) (zip) The trade name under which the Applicant proposes to operate, if any, is: 1 American LegalNet, Inc. www.FormsWorkflow.com 5. If the Applicant is a corporation, state separately the full name and business address of each officer and director of the Applicant: name office address name office address name office address 6. If the Applicant is a partnership or an association or limited liability corporation (other than a Joint Stock Association with fifty (50) or more members), state separately the full name and business address of each member: name office address name office address name office address 7. If the Applicant is a Joint Stock Association having fifty (50) or more members, state the name and business address of the association and each officer and director thereof: Name of Association Name Business Address Office Held Business Address GENERAL QUESTIONS 1. Are you now or have you ever been engaged in the business of selling, issuing or otherwise dispensing checks, drafts, money orders or other instruments for the transmission or payment of money in Alabama or any other state ? YES _______ NO _______ 2. If the answer to Question number (1) is yes, please identify every state in which you have ever engaged in the business. _______________________________________________________________________ 3. Have you ever engaged in the business of selling, issuing or otherwise dispensing checks, drafts or money orders or other instruments for the transmission or payment of money in the State of Alabama prior to the filing of this application? YES ______ NO ______ If so, for how long? ___________________________________________________________________ 4. Please provide in detail a description of your current business. _________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Attach additional pages if needed. 2 American LegalNet, Inc. www.FormsWorkflow.com 5. Please provide in detail you prior business activities. _________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Attach additional pages if needed. 6. Are you now engaged in the business of receiving money as agent for obligors for the purpose of paying obligors’ bills, invoices or accounts? YES ______ NO ______. If you answer yes, please provide details of this business: 7. If the answer to either or both of the previous questions is yes, please provide detail concerning the experience of your officers, managing partners, principals, etc. in this type of business: (attach additional sheet of paper, marked Exhibit A, if necessary) 8. Do you propose to carry on, or engage in, any other business? YES ______ NO ______. If the answer is “yes”, describe other business, or businesses, in detail 9. Do you propose to operate at more than one location within the State of Alabama? YES ______ NO ______ Please state the number of additional locations. _______ 10. If your answer is “yes”, please list each of these locations, stating the business address of each location, and representatives by each location. This exhibit should be marked Exhibit B and attached to this application. DISCIPLINARY QUESTIONS DEFINITIONS: “Applicant” shall mean and include an individual applicant as well as the officers, directors and controlling persons of any proprietorship, corporation, partnership, limited liability corporation or joint stock association applicant. 1. In the past ten years has the applicant been convicted of or pleaded guilty or noloc ontendre (“no contest”) to: 3 American LegalNet, Inc. www.FormsWorkflow.com (a) A felony or misdemeanor involving: Investment or an investment-related business Fraud, false statement, or omission Wrongful taking of property or Bribery, forgery, counterfeiting, or extortion YES ______ NO ______ (b) Any other felony? YES ______ NO ______ 2. Has any other federal regulatory agency or any state regulatory agency: (a) Ever found the applicant to have made a false statement or omission or been dishonest, unfair, or unethical? YES ______ NO ______ (b) Ever found the applicant to have been a cause of a sales of check business having its authorization to do business denied, suspended, revoked, or restricted? YES ______ NO ______ (c) In the past ten years, entered an order against the applicant in connection with a sales of check business? YES ______ NO ______ (d) Ever denied, suspended, or revoked the applicant’s registration or license, prevented it from associating with a sales of check business, or otherwise disciplined it by restricting its activities? YES ______ NO ______ THE APPLICANT, BY THE EXECUTION OF THIS APPLICATION, ACKNOWLEDGES AND AGREES TO BE BOUND BY THE FOLLOWING CONDITIONS AND WARRANTIES: 1. Applicant agrees to operate the business in compliance with all orders, decisions or findings of the Alabama Securities Commission. YES ______ NO ______ 2. The Applicant agrees to maintain adequate records which disclose the true status of the Applicant’s business, and will make such records available for examination, upon request, by representatives of the Alabama Securities Commission. YES ______ NO ______ 4 American LegalNet, Inc. www.FormsWorkflow.com 3. The Applicant agrees to maintain sufficient bank deposit balances at all times to cover the Applicant’s liability on account of checks, drafts, money orders or other instruments for the transmission or payment of money and the receiving of money as agent for obligors. YES ______ NO ______ 4. The Applicant agrees to deliver to the Alabama Securities Commission the license issued by the Commission if the same is not renewed or if the license is revoked or voluntarily surrendered. YES ______ NO ______ 5. The Applicant agrees that, upon receiving a license under the Act, it will maintain a bank deposit account for the business for which this license application is being filed. Applicant will keep and maintain in this account, at all times, a minimum amount equal to all outstanding liabilities. YES ______ NO ______ OBLIGOR AGENT QUESTIONNAIRE The following information is to provide documentation that your business of receiving money as an agent for obligors will be conducted honestly, fairly, equitably, carefully, and efficiently. The answers should be detailed and complete. 1. (a) Describe the process whereby this company will receive obligors money, account for such receipt, safeguard such money, and transmit the money to the designated oblige. (b) Do you maintain any form of general procedures manual? If so, please attach a copy to this application. 2. Describe the audit procedure used to verify the processing steps described in response to question 1(a). A statement from your accountant supporting this answer will be helpful and may be required. 3. Will a separate bank account be used for the deposit of the obligor’s money and the transmittal of money to obligees? Name and address of bank: Account No: 5 American LegalNet, Inc. www.FormsWorkflow.com SIGNATURE OF APPLICANT For sole proprietor (Proprietor) For Partnership (Name of partnership) BY (General Partner) (Seal of Corporation) For Corporation, etc. (Name of Corporation) BY (Name) ITS: (Title) For Limited Liability Corporation, Limited Liability Partnership BY (Its Managing Member/Shareholder) This application must be executed by a principal officer, partner or principal on behalf of the Applicant. Please complete the attached Reference form with your application. STATE OF SS. COUNTY OF The undersigned being duly sworn deposes and says that he has executed the foregoing application for and on behalf of the applicant named therein, that he is _______________________________________ of such applicant and is fully authorized to execute and file such application; that he is familiar with such application; and that to the best of his knowledge, information and belief, the statements made in such application and the statements made in the exhibits submitted therewith, are true. Subscribed and sworn to before me this _______ day of ______________, 20____. (Notary Public) My commission expires: 6 American LegalNet, Inc. www.FormsWorkflow.com REFERENCES The following are the names and address of five references submitted on behalf of the Applicant for a license issued pursuant to the Sale of Checks Act. Name Address State 1 2 3 4 5 7 American LegalNet, Inc. www.FormsWorkflow.com