State of California Secretary of State Immigration Consultant Disclosure (Business and Professions Code section 22443.1) There is no fee for filing the Immigration Consultant Disclosure form. IMPORTANT - Read instructions before completing this form. This Space For Filing Use Only NAME AND CONTACT INFORMATION OF IMMIGRATION CONSULTANT 1. Name of Immigration Consultant 2. Date of Birth (MM/DD/YYYY) 3. Residence Address of Immigration Consultant City State Zip Code 4. Business Address of Immigration Consultant City State Zip Code 5. Residence Phone Number (including area code) 6. Business Phone Number (including area code) CONVICTIONS (All convictions must be disclosed including convictions dismissed under Penal Code section 1203.4 or 1203.4(a).) 7. 8. Have you ever been convicted of a violation of Section 6126 or of Division 8, Chapter 19.5 of the Business and Professions Code? Have you ever been arrested or convicted of a crime, including a crime dismissed under Penal Code section 1203.4 or 1203.4a? YES YES NO NO AGENT FOR SERVICE OF PROCESS OF IMMIGRATION CONSULTANT, IF ANY 9. Name of designated Agent for Service of Process 10. Street Address of designated Agent for Service of Process in California City State CA Zip Code EMPLOYER (BY A CORPORATION OR PARTNERSHIP ONLY) INFORMATION, IF ANY (If the immigration consultant is employed by a corporation or partnership, complete Items 11, 12 and 13. If the employer corporation or partnership has an agent for service of process, complete Item 14. If the agent is an individual, the agent must reside in California and both Items 14 and 15 must be completed. If the agent is a corporation, the agent must have a current certificate pursuant to Corporations Code section 1505 on file with the California Secretary of State and only Item 14 must be completed (leave Item 15 blank).) 11. Name of Employer Corporation or Partnership 12. Business Phone Number (including area code) 13. Business Address 14. Name of Employer's designated Agent for Service of Process 15. If an individual, Street Address of Employer's designated Agent for Service of Process City State CA Zip Code 16. I declare that the information in this disclosure form is true, correct and complete. Signature SF-ICD-465 Rev 04/2015 Date Type or print name APPROVED BY SECRETARY OF STATE American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Completing the Immigration Consultant Disclosure Form For easier completion, this form is available on the Secretary of State's website at www.sos.ca.gov/businessprograms/special-filings and can be viewed, filled in and printed from your computer. The completed form can be mailed to Secretary of State, Special Filings Unit, P.O. Box 942870, Sacramento, CA 94277-2870. If you are not completing this form online, please type or legibly print in black or blue ink. This form should not be altered. This form is filed only in the Sacramento office. An immigration consultant is required to file an Immigration Consultant Disclosure form with the Secretary of State, along with a surety bond, and must pass a background check prior to engaging in the business or acting in the capacity of an immigration consultant. An immigration consultant must notify the Secretary of State's office in writing within 30 days when the surety bond is renewed, and of any change of name, address, telephone number, or agent for service of process. Statutory provisions for this disclosure form are found in Business and Professions Code section 22443.1. There is no fee to file the disclosure form. Along with the completed disclosure form, it is necessary to submit the following items: Copy of valid and current photo identification. Acceptable forms of identification are: 1. 2. 3. 4. 5. An identification card or driver's license issued by the California Department of Motor Vehicles. A passport issued by the Department of State of the United States. An identification card issued by a state other than California. A driver's license issued by a state other then California. An identification card issued by any branch of the armed forces of the United States. 2" x 2" passport photo. Complete the Immigration Consultant Disclosure form as follows: Items 1-6. Enter the name, date of birth (month, day and year), residence and business addresses, and residence and business telephone numbers (including area code) of the immigration consultant. Item 7. Check "Yes" or "No" if the immigration consultant has ever been convicted of a violation of Section 6126 (relating to the unauthorized practice or attempted practice of law without a license) or of Division 8, Chapter 19.5 of the Business and Professions Code (relating to immigration consultants). Check "Yes" or "No" if the immigration consultant has ever been arrested or convicted of a crime, including a crime dismissed under Penal Code section 1203.4 or 1203.4a. Enter the name of the immigration consultant's agent for service of process in California, if any. An agent is an individual who resides in California designated to accept any legal documents that may be served upon the immigration consultant. If an agent for service of process is entered, enter the individual's business or residence street address in California. Do not enter "in care of" (c/o) or abbreviate the name of the city. A post office box is not acceptable. Item 8. Item 9. Item 10. Items 11-13. If the immigration consultant is employed by a corporation or partnership, enter the name, business addresses, and business telephone number (including area code) of the corporation or partnership. Item 14. If the immigration consultant is employed by a corporation or partnership, enter the name of the agent for service of process in California of the corporation or partnership. An agent is an individual who resides in California or a corporation designated to accept any legal documents that may be served upon the corporation or partnership. If a corporation is designated as agent, that corporation must have a current certificate filed with the Secretary of State pursuant to Corporations Code section 1505. If an individual is designated as agent, complete Items 14 and 15. If a corporation is designated as agent, complete Item 14 only and proceed to Item 16 (do not complete Item 15). If an individual is designated as agent for service of process, enter a business or residence address in California. Do not enter "in care of" (c/o) or abbreviate the name of the city. Do not enter an ad