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 INTERNET: www.state.ar.us/arsec CHECK ISSUER CI Form 001 APPLICATION FOR LICENSE NOTE: PLEASE SUBMIT ORIGINAL FORMS ONLY; THE DEPARTMENT WILL NOT ACCEPT FAXED COPIES. PLEASE RETAIN A COPY FOR YOUR RECORDS. INCOMPLETE APPLICATIONS WILL BE RETURNED FOR COMPLETION. Initial Application Processing Fee Initial License Fee (Prorated) $1,500.00 $750.00 x ( /12 ) (Number of months remaining in year) Total Fee (Non-refundable) 1. Name of Applicant: If business is operating in Arkansas under one or more assumed names (DBA), list name(s) below: (Attach a copy of the “Registered Fictitious Name” Certificate issued by the Arkansas Secretary of State’s Office for each assumed name listed.) 2. Principal Office Address: (Must be a physical address.) Address City State Zip Website Telephone Number Mailing address: (If different from above.) Fax Number Address City CI Form 001 State Zip Page 1 of 6 Effective Date: December 1, 2003 American LegalNet, Inc. www.USCourtForms.com 3. Form of Organization (Sole Proprietorship, Partnership, Corporation, Limited Liability Company, etc.) (Attach a copy of the articles of incorporation, articles of partnership, or other such documents of organization filed with the appropriate regulatory authority in the State of organization, as well as copies of any documents issued by said regulatory authority granting approval of said filing. Additionally, attach are copies of any documents issued by the Arkansas Secretary of State granting approval to conduct business in Arkansas as a “foreign corporation”, if applicable.) Federal Employer Identification Number Date fiscal year ends: If publicly traded, give stock symbol: State of Incorporation/Organization: Date of Incorporation/Organization: 4. List the applicant’s affiliates. Complete CI Form 002 and attach. 5. List all persons having an interest in the business as principals, partners, officers, trustees, directors or managers. Complete CI Form 003 and attach. 6. List all states in which the Applicant is licensed to conduct business that includes the name, address, and telephone number of the regulatory authority for each state listed, as well as the license number for each state. Complete CI Form 004 and attach. 7. List all agents and locations conducting business in the State of Arkansas. Complete CI Form 005 and attach. 8. Attach the appropriate Arkansas corporate surety bond (CI Form 006) OR a deposit of cash or securities issued by the federal government, the State of Arkansas, or any political subdivision thereof, in the appropriate amount accompanied by an executed Arkansas “Assignment and Escrow Agreement” form (CI Form 007). The Applicant MUST use CI Form 006 or CI Form 007. No other forms will be accepted. 9. Attach audited financial statements that reflect a net worth of not less than $500,000.00 prepared by an independent certified public accountant and accompanied by an unqualified opinion. The audited financial statements must be as of a date not preceding twelve months of the application date. CI Form 001 Page 2 of 6 Effective Date: December 1, 2003 American LegalNet, Inc. www.USCourtForms.com 10. Applicant Contact Information Licensing Contact Name Title Company Telephone Number Address Fax Number City State Zip E-mail Address Regulatory/Compliance Contact Name Title Company Telephone Number Address Fax Number City State Zip E-mail Address Consumer Complaints Contact Name Title Company Telephone Number Address Fax Number City CI Form 001 State Zip E-mail Address Page 3 of 6 Effective Date: December 1, 2003 American LegalNet, Inc. www.USCourtForms.com 11. Please read the following questions carefully. Details to affirmative responses must be reported on the next page. Please list date(s), court name, case number, party(ies) and court ruling or judgment amount for each matter reported. (a) Are there any criminal proceedings pending or criminal convictions entered against the Applicant, its partners, directors, executive officers or controlling persons? Yes No (b) Are there any civil proceedings pending or civil judgments entered against the Applicant, its partners, directors, executive officers, or controlling persons, which allege fraud or involve fraud or dishonesty or any other act of moral turpitude? (Moral turpitude defined: Moral turpitude involves duties owed by persons to society as well as acts contrary to justice, honesty, principle or good morals. It includes, but is not limited to, theft, extortion, obtaining property under false pretenses, tax evasion, and the sale of (or intent to sell) controlled substances.) Yes No (c) Have any civil judgments been entered against the Applicant, its partners, directors, executive officers or controlling persons, during the past 10 years which have remained partially or wholly unpaid? Yes No (d) Has the Applicant been involved in any of the following proceedings, either pending or resolved: bankruptcy, assignment for the benefit of creditors, receivership, conservatorship or any similar proceeding? Yes No (e) Has the Applicant, or any partner, director, executive officer of the Applicant, been convicted of a felony or misdemeanor involving theft, embezzlement, forgery, obtaining money under false pretenses, conspiracy to defraud, or like defense? Yes No (f) Has the Applicant or any partner, director, executive officer or controlling person ever been involved in any of the following proceeding from a federal or state regulatory/licensing agency either pending or resolved: revocation, suspension, forfeiture, judgment or any similar proceeding? Yes No CI Form 001 Page 4 of 6 Effective Date: December 1, 2003 American LegalNet, Inc. www.USCourtForms.com Instructions. This page should be used to report details of affirmative responses to questions on the previous page. Identify the question number for which additional information is being provided and insert the requested information. Copy this page as necessary and attach. Item No. CI Form 001 Answer Page 5 of 6 Effective Date: December 1, 2003 American LegalNet, Inc. www.USCourtForms.com 12. Attach an executed Arkansas “Consent to Service of Process” form. Complete CI Form 008 and attach.. STATE OF COUNTY OF ) ) ) Under the penalties of perjury, I affirm that I have examined this application and any accompanying information, and to the best of my knowledge and belief it is true, correct and complete. Furthermore, I am authorized to make this application and sign this statement on behalf of the Applicant. The Applicant and its employees will comply with the provisions of Ark. Code Ann. § 23-41-101, et seq., (Sale of Checks Act). I understand that non-compliance could result in a suspension or revocation of the Applicant’s license. Pursuant to the Sale of Checks Act, the Applicant authorizes the Arkansas Securities Commissioner to conduct a financial and business responsibility background check as may be required to determine the general character and fitness of the Applicant, or any of its partners, directors, executive officers, and/or controlling persons to engage in the business of selling or issuing checks, money orders, or other instruments for the transmission or payment of money as a service or for a fee or other consideration.. Further, the Applicant, its partners, directors, and executive officers or controlling persons hereby authorize the release of requested information necessary to facilitate the final determination of the Applicant by the Arkansas Securities Commissioner. It is further understood and affirmed that any response to an inquiry made by the Arkansas Securities Commissioner, with respect to the Applicant, its owners, partners, directors, and executive officers or controlling persons, is provided solely as a matter of courtesy and that any person, organization or governmental entity providing such a response shall not be liable for the content or use of such information except in the event of willful negligence. (Signature) Date (Print Name) Title Subscribed and sworn to before me this ________ day of ________________, __________. NOTARY PUBLIC My Commission Expires: CI Form 001 Page 6 of 6 Effective Date: December 1, 2003 American LegalNet, Inc. www.USCourtForms.com