Read reverse side before completing.BACKGROUND INFORMAT þiI ON 1. þ NAME OF DIRECTOR, þOO FFICER, STOCKHOL þdD ER, ETC. ( þsS EE REVER þsS E.) þ 2. þC C ORPORATIO þnN NAME þ 3.þ D þRERE þCC ORP. þLICELICE NS þEE þII D# (IF ISSUED)4. þP P O þsS ITIO þnN / þTT ITLE WITH þCC ORPORATE þLL ICE þnsNS E þAA PPLICA þnN T þ 5. þ BIRTH DATE6. þW W ITHI þnN THE LA þsS T TE þnN YEAR þsS , HAVE YOU RECEIVE þdD A þnN OR þdD ER OR JU þdD GME þnN T I þssSS UE þdD þbB Y A COURT OR GOVER þnN ME þnN TAL AGE þnN CY TEMPORARILY OR PERMA þnN E þnN TLY RE þsS TRAI þnN I þnN G OR E þnN JOI þnN I þnN G A þnN Y þbB U þsS I þnN E þssSS CO þndND UCT, PRACTICE, OR EMPLOYME þnN T? þ þYY es þ No þI I F þYEYE S, COMPLETE THE FOLLOWI þnN G. þ þDD ATE OF þAA CTION þA A GENCY/ þCC OURT þC C ASE # þA A DDRESS þE E XPLANATION7. þW W ITHI þnN THE LA þsS T TE þnN YEAR þsS , HAVE YOU HA þdD A þbB U þsS I þnN E þssSS /PROFE þssSS IO þnN AL LICE þnsNS E TO PRACTICE I þnN REAL E þsS TATE OR OTHER REGULATE þdD PROFE þssSS IO þnN , OCCUPATIO þnN , OR VOCATIO þnN þdD E þnN IE þdD , þsS U þsS PE þndND E þdD , RE þsS TRICTE þdD , OR REVOKE þdD I þnN þCC ALIFOR þnN IA OR A þnN Y OTHER þsS TATE? þAA TTACH ADDITIONAL SHEETS IF NECESSARY. þ þYY es þ No þI I F þYEYE S, COMPLETE THE FOLLOWI þnN G. þTT YPE OF þLL ICENSE þL L ICENSE þEE XPIRATION þDD ATE þL L ICENSE þII DENTIFICATION # þS S TATE (ISSUED BY)8. þW W ITHI þnN THE LA þsS T TE þnN YEAR þsS , HAVE YOU CO þndND UCTE þdD ACTIVITIE þsS I þnN VOLVI þnN G ACT þsS REQUIRI þnN G A REAL E þsS TATE LICE þnsNS E OF A þnN Y þsS TATE WITHOUT THE þbB E þnN EFIT OF A VALI þdD LICE þnsNS E OR PERMIT AUTHORIZI þnN G THAT CO þndND UCT, WHICH HAVE þbB EE þnN E þnN JOI þnN E þdD þbB Y A COURT OF LAW OR A þdD MI þnN I þsS TRATIVE TRI þbB U þnN AL? þ þYY es þ No þI I F þYEYE S, COMPLETE THE FOLLOWI þnN G. þ þCC OURT OF þCC ONVICTION þC C ASE # þA A RRESTING þAA GENCY þD D ATE OF þCC ONVICTION þC C ODE þNN UMBER þVV IOLATED þC C ODE þSS ECTION þVV IOLATED þD D ISPOSITION" þCC onvicted" as used in question 9 below includes: þCC onvictions expunged under Penal þCC ode sections 1203.4, 1203.4a and 1203.41 or equivalent non- þCC alifornia statute must still be disclosed. Proof that a conviction has been expunged under Penal þCC ode sections 1203.4, 1203.4a and 1203.41 must be submitted with the application.Exceptions to " þCC onvicted": þDODO þNOTNOT þDD IS þCC L þOO SE þAFTAFT E þRR þ 9. þW W ITHI þnN THE LA þsS T TE þnN YEAR þsS , HAVE YOU þbB EE þnN CO þnN VICTE þdD OF A þnN Y VIOLATIO þnN OF LAW? ( þYY OU MAY OMIT MINOR TRAFFIC CITATIONS WHICH DO NOT CONSTITUTE A MISDEMEANOR OR FELONY.) þAA TTACH A þddDD ITIO þnN AL þsS HEET þsS IF þnN ECE þssSS ARY. þ þYY es þ No þI I F þYEYE S, COMPLETE THE FOLLOWI þnN G. þC C OURT OF þCC O þnN VICTIO þnAN A RRE þsS TI þnN G þAA GE þnN CY þ DATE OF þCC O þnN VICTIO þnNþC C O þdD E NUM þbB ER þVV IOLATE þdCD C O þdD E SECTIO þnN þVV IOLATE þdD DI þsS PO þsS ITIO þnNþCeCE RT þiI F þiI CAT þiI ON þII declare under penalty of perjury that the answers and statements given in this þBB ackground þSS tatement are true and correct except where stated upon information and belief. þ You should review your application to insure it has been properly completed. þFF ailure to complete required portions of the application could result in either processing delays or denial of the license. þ þi þa þi þc þhi þE þc þi þO þic þc þ þ þa STATE OF CALIFORNIADEPARTMENT OF þRREAL þEEþsSTATECORPORATION BAþcCKGROUND STATEMENT RE 212 (Rev. 7/18) American LegalNet, Inc. www.FormsWorkFlow.com IN þsS TRUCT þiI ON þsSþRERE 212 227 þRR everse þ A separate RE 212 must be completed by each director, þ Please type or print in ink. þ þ þ þ Failure to provide complete answers to all of the following questions could result in either processing delays or denial of the license. PRIVACY INFORMATION: þ þ þ American LegalNet, Inc. www.FormsWorkFlow.com