STATE OF CALIFORNIA DEPARTMENT OF BUSINESS OVERSIGHT NOTICE OF OFFICERS, DIRECTORS, MANAGERS, MEMBERS, TRUSTEES AND EMPLOYEES OF A CAPITAL ACCESS COMPANY DBOCACL 280.153 (Rev. 10-17) OFFICIAL USE ONLY LAST NAME Date submitted CII: Applicant I.D.# Fee: $20.00 + DOJ Noncriminal Applicant Fingerprint Fee (Fees should include the Department of Business Oversights and the fee charged by the Department of Justice [Penal Code Section 11105] for processing Noncriminal Applicant Fingerprints.) Receipt No. PLEASE PRINT OR TYPE NAME OF COMPANY: FILE NO. ADDRESS OF MAIN OFFICE: (Street) (City) (State) (Zip Code) EMPLOYING BRANCH OFFICE: TRUSTEE AND EMPLOYEE: (Last) (First) (Middle) POSITION HELD OR TO BE HELD: HOME ADDRESS: (Street) (City) (State) (Zip Code) DATE OF BIRTH: PLACE OF BIRTH: (Month) (Day) (Year) HEIGHT: WEIGHT: SEX: COLOR OF EYES: COLOR OF HAIR: * This document shall be treated by the Department of Business Oversight as being received in confidence pursuant to paragraph (4) of subdivision (d) of Section 6254 of the Government Code. American LegalNet, Inc. www.FormsWorkFlow.com