STATE OF ARKANSAS SECURITIES DEPARTMENT HERITAGE WEST BUILDING, SUITE 300 201 EAST MARKHAM STREET LITTLE ROCK, AR 72201 TELEPHONE: 501.324.9260 FAX: 501.324.9268 Website: www.securities.arkansas.gov FMLA Form 014 APPLICATION FOR MANAGING PRINCIPAL, BRANCH MANAGER OR LOAN OFFICER NOTE: PLEASE SUBMIT ORIGINAL FORMS ONLY; THE DEPARTMENT WILL NOT ACCEPT FAXED COPIES. PLEASE RETAIN A COPY FOR YOUR RECORDS. INCOMPLETE FORMS WILL BE RETURNED FOR COMPLETION Application Fee (Loan Officer License Only) See the 2008 Fee Schedule. This fee is non-refundable. Mark Appropriate Box: Check all that apply: New Application Managing Principal Amended Application Branch Manager Loan Officer $________ Current Employer: Employer's Arkansas License Number: Mr. Full Legal Name: SSN: Home Address: (Must be physical address, No P. O. Box ) City State Zip Code Website 1. Ms. DOB: DLN: State: Business Address: (Must be physical address, No P. O. Box) City State Zip Code Business Telephone Number Business E-mail Address: Business Facsimile Number High School Diploma/GED Date Earned: FMLA Form 014 Page 1 of 3 Effective Date: February 1, 2005 Amended: August 1, 2007 American LegalNet, Inc. www.FormsWorkFlow.com 2. Date To/From Employment Record for Last Five Years (If unemployed anytime during this period, so indicate) Name and Address of Employer (List your most recent employer first) Position Held and Nature of Duties 3. Please read the following questions carefully. Details to affirmative responses must be attached to this form. Please list date(s), court name, case number, all parties and court ruling or judgment amount for each matter reported. (a) Have you ever pled guilty or nolo contendere to, or been convicted of a crime punishable by one or more years imprisonment? To the best of your knowledge, are you a subject of any pending criminal investigation or proceeding? Have you been a subject of any action, order or proceeding, pending, or concluded, by any state or federal agency regulating the mortgage banking, mortgage brokering, or mortgage servicing industries during The past five (5) years? Have you ever been a subject of any action, order, or proceeding by any state or federal agency regulating the banking industry, securities industry, insurance industry, or any other financial services industry during the past five (5) years? Have there been any civil judgments entered against you arising from complaints alleging fraud, dishonesty, misrepresentation, theft, misappropriation, bad faith, deceptive trade practices, or predatory lending practices during the past five (5) years? Have you been named as a defendant in any pending civil court proceeding in which a complaint alleges fraud, dishonesty, misrepresentation, theft, misappropriation, bad faith, deceptive trade practices, or predatory lending practices? Yes No (b) Yes No (c) Yes No (d) Yes No (e) Yes No (f) Yes No FMLA Form 014 Page 2 of 3 Effective Date: February 1, 2005 Amended: August 1, 2007 American LegalNet, Inc. www.FormsWorkFlow.com 4. Beginning with the calendar year 2007, all loan officers that have held a loan officer license for a period, whether consecutive or not, of one hundred eighty (180) days or more, during the calendar year for which continuing education hours are required shall complete eight (8) hours of continuing education annually, at least one (1) hour of which shall be on mortgage industry ethics, by December 31; provided, however, that any continuing education approved by the Commissioner and completed during calendar year 2006 may be applied toward the 2007 requirement. (a) an hour of continuing education shall consist of course instruction of fifty (50) minutes; (b) if a licensee acquires in excess of eight (8) approved continuing education hours in one calendar year, the excess credit may be carried forward and applied to the continuing education requirement for the next calendar year only up to a maximum of eight (8) hours. (c) Please indicate in the appropriate box the name of the Approved Provider, date of completion of course and total number of hours received. Date of Completion: I. D. Number: Approved Provider: Hours Completed: STATE OF COUNTY OF I will comply with the provisions of Ark. Code Ann.§23-39-501, et seq., (Fair Mortgage Lending Act). I understand that non-compliance may result in a suspension or revocation of my license. I further understand that any license issued is non-transferable. I understand that I may be employed by only one Mortgage Banker or Broker at a time. I further understand that, if licensed, my license is terminated when I change employment and I must apply for a new license if employed by another Licensed Mortgage Banker or Broker. Pursuant to the Fair Mortgage Lending Act, I authorize the Arkansas Securities Commissioner to investigate any sources deemed necessary to establish and monitor my financial responsibility, honesty and experience. To this end, I authorize any company or person named herein to furnish information requested by the Arkansas Securities Commissioner. I further understand that, if licensed, my license is terminated during any period that I am not employed by a Licensed Mortgage Banker or Broker, and if there is a material change in any of the information contained in this application, including address changes, I must provide the Arkansas Securities Commissioner with updated information within thirty (30) days of such change. I hereby swear or affirm that I have reviewed this application and the accompanying information submitted herein, and that that the information contained therein is true, accurate, correct and complete to the best of my knowledge. I understand that the submission of false information to the Arkansas Securities Commissioner could result in the revocation or suspension of my license. I understand that it is unlawful pursuant to Section § 23-39-516(a) of the Arkansas Fair Mortgage Lending Act for any person to make or cause to be made, in any document filed with the Arkansas Securities Commissioner, any statement that is, at the time and in light of the circumstances under which it is made, false or misleading in any material respect. Further, I understand that making or causing to be made a false or misleading statement as described above, if made willfully in a document filed with the Arkansas Securities Commissioner, is a Class B felony pursuant to Ark. Code Ann. § 23-39-516(b), and carries a penalty of not less than five (5) years