IL LB FORM 15-10 Application for Registration as a Loan Broker Illinois Secretary of State Securities Department 421 E. Capitol Ave., 2nd Floor Springfield, IL 62701 217-782-2256 Application to register with the Office of the Illinois Secretary of State, Securities Department, pursuant to the Illinois Loan Brokers Act of 1995. 1. Name of Applicant (if an individual or sole proprietor, state last name, first name and middle name): 2. 3. 4. 5. Social Security Number or F.E.I.N.: Telephone Number: Name under which Loan Broker business primarily is conducted, if different: Firm's Main Address (If P.O. Box, must have legal address.): Include Addresses of all Branch Offices in Illinois on an additional sheet. Street Address (LEGAL) City, State, ZIP Street Address (MAILING, IF DIFFERENT) City, State, ZIP 6. Contact Person: Name Fax Number Business Telephone Number Email Address 7. Date and Place Applicant obtained Legal Status: Date of Formation State of Formation Type of Legal Status: Corporation Partnership Sole Proprietorship Limited Liability Company Limited Liability Partnership 8. If Sole Proprietor, full Residence Address and Social Security Number: Street Address City, State, ZIP Social Security Number 9. If at the time of this filing, the Applicant is succeeding to the business of a currently registered Loan Broker: a. b. c. Date of Succession: ___________________________________________________________________________________________ Name of Predecessors:_________________________________________________________________________________________ IRS Employer Identification Number: ______________________________________________________________________________ Printed by authority of the State of Illinois. November 2015 -- 100 -- SEC 327.2 American LegalNet, Inc. www.FormsWorkFlow.com 10. Nature and Place(s) of Business of the Applicant or Employment History (if an individual) for the past 10 years or for the period of existence if less than 10 years: 11. Background Information -- For the purposes of this section only, Applicant also includes principals, officers, directors, partners, members, trustees, managers or any similar individual. Mark each question "yes" or "no." If the answer to any question is "yes," provide a detailed explanation and/or documentation on an additional sheet. a. In the past 10 years has the Applicant been convicted of or pleaded guilty or nolo contendre (no contest) in a domestic or foreign court to: 1. A felony or misdemeanor involving: investment, financial, loan broker or related business fraud, false statement, or omissions, wrongful taking of property, or bribery, forgery, counterfeiting or extortion: Yes No 2. Any felony (other than listed above): Yes No Has any domestic or foreign court in the past 10 years enjoined the applicant in connection with investment, financial or business related activity: Yes No Has any other federal regulatory agency, state regulatory agency or foreign financial regulatory authority: 1. Ever found the applicant to have made a false statement or omission, or been dishonest, unfair or unethical? Yes No 2. Ever found the applicant to have been involved in a violation of investment, business or financial regulations or statutes? Yes No 3. Ever found the applicant to have been a cause of a loan broker, investment or financial related business having its authorization to do business denied, suspended, revoked, restricted or otherwise adversely affected? Yes No 4. In the past 10 years, entered an order against the applicant in connection with an investment, financial or loan broker related activity? Yes No 5. Ever denied, suspended, revoked or otherwise adversely affected the applicant's registration or license, prevented it from associating with an investment, financial or loan broker related business, or otherwise disciplined it by restricting its activities? Yes No 6. Ever revoked, suspended or otherwise adversely affected the applicant's license as an attorney or accountant? Yes No Has any foreign government, court or regulatory authority ever entered an order against the applicant related to financial activity or fraud other than as reported above? Yes No Is the applicant now the subject of any proceeding that could result in a "yes" answer to any parts of Section 11? Yes No Has a bonding company denied, paid out on or revoked a bond for the applicant? Yes No Does the applicant have any material unsatisfied judgements or liens against it? No Yes b. c. d. e. f. g. American LegalNet, Inc. www.FormsWorkFlow.com 12. Name, Residence, Business Address and 10-year occupational statement for each principal of the Applicant. (If a Corporation, provide information for all officers, directors or other persons with similar positions. If a Sole Proprietorship, Partnership, Limited Partnership, Limited Liability Company, Unincorporated Association, Limited Liability Company or any similar form of business organization, provide information for those person(s) who may legally bind the organization. For more space, attach additional sheets.) Name Business Street Address City, State, ZIP Social Security Number Home Street Address City, State, ZIP 10-Year Occupational History: Name Business Street Address City, State, ZIP Social Security Number Home Street Address City, State, ZIP 10-Year Occupational History: Name Business Street Address City, State, ZIP Social Security Number Home Street Address City, State, ZIP 10-Year Occupational History: Date Name of Applicant Signature Name and Title (type or print) American LegalNet, Inc. www.FormsWorkFlow.com