APPLICATION FOR REGISTRATION AS A PRINCIPAL MANAGER OR AN ORIGINATOR State Form 49718 (R5 / 6-08) / Form LB 4 Approved by State Board of Accounts, 2008 Explanation and Instructions Before completing this Application for Registration as a Principal Manager or an Originator, you should read and be familiar with the Indiana Loan Broker Act, codified in Indiana Code 23-2-5 and the rules relating to the Act which are contained in Indiana Administrative Code 710 IAC 1-22. You may access the statutes and rules through the Division’s website: www.sos.IN.gov/securities. This properly completed application must be accompanied by: • A $200 non-refundable application fee for registration as a principal manager or a $100 non-refundable application fee for registration as an originator, plus $32.25 for an FBI background check payable to: “Indiana Secretary of State.” • Complete set of fingerprints on an FBI fingerprint card (FD258) • Certificate of completion of academic instruction course(s) • Evidence that applicant for registration as a principal manager has three years of experience, acceptable to the Commissioner as a loan broker or in financial services (if applicable); and • Any additional documentation needed to answer questions. • DO NOT include the instructions (pages 1-4 of this form) NOTE: The certificate of registration will not be issued until the required criminal background report(s) has been received and reviewed by the Secretary of State, Securities Division. A PERSON WHO KNOWINGLY FILES WITH THE COMMISSIONER ANY DOCUMENT OR STATEMENT THAT CONTAINS A FALSE REPRESENTATION OF A MATERIAL FACT IS SUBJECT TO THE REGISTRATION BEING DENIED, SUSPENDED, OR REVOKED; THE IMPOSITION OF A CIVIL PENALTY OF UP TO $10,000 PER VIOLATION; AND CHARGED WITH A CLASS C FELONY WHICH IS PUNISHABLE BY A FINE UP TO $10,000 PER VIOLATION AND UP TO EIGHT (8) YEARS OF IMPRISONMENT. If the space provided for any answer is inadequate, complete your answer on a separate sheet, specifying the question to which it relates and attach this sheet to the application. For each additional sheet you provide, sign and list the applicant’s name. Submit your properly completed application along with any supporting documentation to the following address: Indiana Secretary of State Securities Division 302 W. Washington St., Room E – 111 Indianapolis, Indiana 46204 A. GENERAL INSTRUCTIONS 1. TERMS USED – See the following Explanation of Terms section regarding italicized words/phrases used throughout the State Form 49718/Form LB 4. 2. CHECK whether you are applying for registration as a principal manager or as an originator. 3. AMENDMENTS – The applicant must notify the Division as required by Indiana Code § 23-2-5-10(i) of a change in any information contained in this form by submitting amendments using State Form 49718/Form LB 4 within two business days of the change. Check the “Amend Existing Registration” box, enter the registration number, submit the name of the applicant in Section 1(A), circle (or otherwise identify) and complete the information that is being amended, and complete Section 9. If the amendment filing is to change the individual’s name, enter the previous name in Section 1(A) and the new name in Section 1(H). Appropriate supporting documentation includes, but is not limited to, copies of marriage certificates, divorce decrees, or other legal documents evidencing both the prior and new names. 4. SURRENDER / CANCEL – When an applicant decides to cease activity under the registration, use State Form 49718/Form LB 4 to notify the Secretary of State, Securities Division by checking the “Surrender/Cancel” box. Use this notification for various reasons including voluntarily leaving the industry, surrender in lieu of revocation, gained exemption status, etc. Complete Sections 1(A), 4, and 9 then send the original certificate of registration along with the State Form 49718/Form LB 4 to the Secretary of State, Securities Division. State Form 49718 (R5 / 6-08) / Form LB 4 Page 1 of 10 American LegalNet, Inc. www.FormsWorkflow.com A. GENERAL INSTRUCTIONS CONTINUED 5. FBI Criminal Background Check: Pursuant to Indiana Code § 23-2-5-5(k)(2) applicants for registration as a principal manager or an originator must undergo an FBI criminal background check. The following applies to all individuals: Complete the following steps: 1. Obtain an FBI fingerprint card (FD258) from a law enforcement agency, preferably a state police post. 2. Present a valid form of ID and get fingerprinted, making sure to avoid smudging or other means of rendering the fingerprints illegible. An illegible fingerprint will result in having to start the process over including repayment of the background check fee. 3. Mail the finished fingerprint card along with your completed application to the following address: Indiana Secretary of State Securities Division 302 W. Washington St., Room E-111 Indianapolis, IN 46204 BE ADVISED: Failure to submit the required complete fingerprint card issued by a law enforcement agency with the appropriate certification will delay the processing of your application. The Division will NOT issue a license or a certificate of registration without the legible fingerprint card. 6. TYPE OR PRINT. Illegible or incomplete applications will be returned. B. SECTION INSTRUCTIONS SECTION 1 – INDIVIDUAL’S IDENTIFYING INFORMATION Complete each line. The name on the registration certificate will appear exactly as reported in 1(A). In Section 1(J), list the employer’s principal office address registered with the Indiana Secretary of State, Securities Division and in Section 1(K) list the office location where the applicant will be serving as a principal manager or conducting origination activities if different from the principal office address listed in Section 1(J). SECTION 2 – ACADEMIC INSTRUCTION & TESTING An applicant must provide evidence that they have satisfied the academic instruction requirements established by Indiana Code § 23-2-5-21(a) and Indiana Administrative Code 710 IAC 1-22-4. The applicant must also pass the required registration examination pursuant to Indiana Code § 23-2-5-5(d). Instructions of how to register and complete the registration examination can be found on the Securities Division’s website: http://www.in.gov/sos/securities/loanBroker/ISOS_Candidate_Guide.pdf In this section, list the name of the course vendor, name of the course, and number of credit hours completed in Section 2 and attach to this application a copy of the certificate of completion of the academic instruction course(s) as well as a copy of exam results. Use additional sheets as needed. INITIAL APPLICANTS: must have completed twenty-four (24) live hours of approved academic instruction in the previous twenty-four (24) months. Within their initial twenty-four (24) hours of academic instruction, the applicant must complete at least one (1) hour of academic instruction on Indiana loan broker law and at least two (2) hours of academic instruction on federal loan broker law. Additionally, the applicant must pass the required registration examination. RENEWAL APPLICANTS: must have completed at least six (6) hours of approved academic instruction during each calendar year following the year in which the registration was initially issued and pass the required registration examination. You may view the list of approved courses on the Division’s website: http://www.in.gov/sos/securities/public.html. SECTION 3 – CONSENT TO SERVICE OF PROCESS The Loan Broker Act provides that legal documents relating to proceedings against a principal manager/originator arising from the conduct of the principal manager/originator or out of violation of the laws of Indiana be served upon the Secretary of State’s Securities Division. After accepting service of the documents, the Secretary of State, Securities Division, will forward the documents to the individual appointed as an agent listed in this section. State Form 49718 (R5 / 6-08) / Form LB 4 Page 2 of 10 American LegalNet, Inc. www.FormsWorkflow.com B. SECTION INSTRUCTIONS CONTINUED SECTION 4 – LOAN BROKER VERIFICATION – This section must be completed and signed by an authorized party of the licensed loan broker. 1. ESTABLISH RELATIONSHIP – Applicants must apply to establish an employment relationship with a licensed loan broker by submitting a new registration application (State Form 49718/LB 4). 2. TRANSFER REGISTRATION – A registered principal manager or originator may transfer their registration to another licensed loan broker by filing an amendment. Check the “Amend Existing Registration” box, complete Sections 1(A), 1(I) through 1(M), 4, and 9. The new employer must complete Section 4(A) and the previous employer must complete Section 4(B). The original certificate of registration being withdrawn must be returned to the Secretary of State, Securities Division within five (5) days of the termination as required by Indiana Code § 23-2-5-10(h). 3. TERMINATE RELATIONSHIP – For the purposes of this form, “terminate” refers to the ending of the employment relationship between the registrant and the licensed loan broker. Pursuant to Indiana Code § 23-2-5-10(h)(2) applicants or the employer (licensee) must submit the State Form 49718/Form LB 4 to notify the Secretary of State, Securities Division that the employment relationship has ceased. Sections 1(A), 4(B), 9, must be completed and returned with the original certificate of registration and reason for termination to the Secretary of State, Securities Division within five (5) days of the termination as required by Indiana Code 23-2-5-10(h). Section 4(B) must be completed and signed by an authorized party of the loan broker. SECTION 5 – RESIDENTIAL HISTORY Starting with current address (Section 1(L)), give all addresses for the past ten (10) years, leaving no gaps. (Attach additional sheets as necessary.) Post Office boxes are not acceptable. Report changes as they occur. YOU MUST ACCOUNT FOR ALL TIME LEAVING NO GAPS. SECTION 6 – EMPLOYMENT HISTORY Provide complete employment history for the past ten (10) years, leaving no gaps. All entries must include the beginning and end dates of employment. Provide the full legal name of the company, beginning with your current employer. Account for all time including full & part-time employment, self-employment, military service, and homemaking. Also include periods such as unemployment, full-time student, extended travel, etc. For the purposes of this history, include both 1099 independent contractor assignments as well as W-2 status employment. Indicate by “YES” or “NO” whether this employment was financial service-related business. (Attach additional sheets as needed.) YOU MUST ACCOUNT FOR ALL TIME LEAVING NO GAPS. An applicant for registration as a principal manager must provide evidence that the applicant has at least three (3) years of experience, acceptable to the Commissioner as a loan broker or in financial services. Individuals applying for registration as a principal manager must include a detailed description of the relevant employment, including a description of the duties performed and the name and contact information of the person you reported to. SECTION 8 - DISCLOSURES Questions must be answered fully, and must include all actions or legal proceedings occurring in any court in any jurisdiction. If the answer to any of the questions is “YES”, provide complete details of all events or proceedings in an attachment, listing the offense, cause number, date of conviction, and the court in which the individual was convicted. Additionally for bankruptcies, submit a copy of the discharge paperwork or a statement identifying the current status of the bankruptcy. Refer to the explanation of terms section of the instructions for explanations of italicized terms. SECTION 9 – INDIVIDUAL VERIFICATION By signing the verification, the principal manager/originator is affirming that the application is true and complete, that he/she has not been convicted of a felony within the previous five (5) years or a crime of fraud or deceit within the previous ten (10) years. If the applicant has been convicted of a felony within the previous five (5) years or a crime of fraud or deceit in the previous ten (10) years, this information must be disclosed by attaching additional pages listing the offense, cause number, date of conviction, and the court in which the individual was convicted. The Commissioner may deny registration based on this information. State Form 49718 (R5 / 6-08) / Form LB 4 Page 3 of 10 American LegalNet, Inc. www.FormsWorkflow.com C. EXPLANATION OF TERMS – The following terms are the italicized terms used throughout this State Form 49718/Form LB 4 and have the following meaning. 1. GENERAL APPLICANT – The individual completing and signing the verification located in Section 9 of this application form (State Form 49718/Form LB 4). AUTHORIZED PARTY – for an originator the authorized party is an ultimate equitable owner of the company, an executive officer, or the principal manager at the employment location; for a principal manager the authorized party is a director, executive officer, or ultimate equitable owner of the licensed loan broker CONTROL – The power, directly or indirectly, to direct the management or policies of an entity, whether through ownership of securities, by contract, or otherwise. Any person that (1) directly or indirectly has the right to vote 10% or more of a class of a voting security or has the power to sell or direct the sale of 10% or more of a class of voting securities; (2) in the case of an LLC, Managing Member; or (3) in the case of a partnership, has the right to receive upon dissolution, or has contributed, 10% or more of the capital, is presumed to control that company. JURISDICTION – A state, the District of Columbia, the Commonwealth of Puerto Rico, any territory of the United States, or any subdivision or regulatory body thereof. ORIGINATOR – A person engaged in origination activities. ORGINATION ACTIVITIES – Communication with or assistance of a borrower or prospective borrower in the selection of loan products or terms. PERSON – An individual, a partnership, a trust, a corporation, a limited liability company, a limited liability partnership, a sole proprietorship, a joint venture, a joint stock company, or another group or entity, however organized. PRINCIPAL MANAGER – The individual responsible for the supervision and management of the employees and business affairs of the licensee at a specific office location. ULTIMATE EQUITABLE OWNER – A person who, directly or indirectly, owns or controls ten percent (10%) or more of the equity interest in a loan broker licensed or required to be licensed under Indiana Code 23-2-5, regardless of whether the person owns or controls the equity interest through one (1) or more other persons or one (1) or more proxies, powers of attorney, contracts, or other arrangements. 2. FOR THE PURPOSE OF SECTION 8 CHARGED – Being accused of a crime in a formal complaint, information, or indictment (or equivalent formal charge). ENJOINED – Includes being subject to a mandatory injunction, prohibitory injunction, preliminary injunction, or a temporary restraining order. FELONY – A felony is an offense punishable by a sentence of at least one (1) year imprisonment and/or a fine of at least $1,000. FINANCIAL SERVICES OR FINANCIAL SERVICES RELATED – Pertaining to securities, commodities, banking, insurance, or consumer lending (including, but not limited to; acting as or being associated with a bank or savings association, credit union, mortgage lender, loan broker). FOREIGN FINANCIAL REGULATORY AUTHORITY – Includes (1) a financial services authority of a foreign country; (2) other governmental body empowered by a foreign government to administer or enforce its laws relating to the regulation of financial services or financial services-related activities; and (3) a foreign membership organization, a function of which is to regulate the participation of its members in financial services activities listed above. FOUND – Includes adverse final actions, including consent decrees in which the respondent has neither admitted nor denied the findings, but does not include agreements, deficiency letters, examination reports, memoranda of understanding, letters of caution, admonishments, and similar informal resolutions of matters. INVOLVED – Doing an act or omission or aiding, abetting, counseling, commanding, inducing, conspiring with or failing reasonably to supervise another in doing an act or omission. MISDEMEANOR – A misdemeanor is an offense punishable by a sentence of less than one (1) year imprisonment and/or a fine of less than $1,000. ORDER – A written directive issued pursuant to statutory authority and procedures, including orders of denial, suspension, or revocation; does not include special stipulations, undertakings or agreements relating to payments, limitations on activity or other restrictions unless they are included in an order. PROCEEDING – Includes a formal administrative or civil action initiated by a governmental agency, self-regulatory organization or a foreign financial regulatory authority; a felony criminal indictment or information (or equivalent formal charge); or a misdemeanor criminal information (or equivalent formal charge). The term does not include other civil litigation, investigations, or arrests or similar charges affected in the absence of a formal criminal indictment or information (or equivalent formal charge). State Form 49718 (R5 / 6-08) / Form LB 4 Page 4 of 10 American LegalNet, Inc. www.FormsWorkflow.com Todd Rokita Indiana Secretary of State Securities Division 302. W. Washington Street, E-111 Indianapolis, Indiana 46204 (317) 232-6681 APPLICATION FOR REGISTRATION AS A PRINCIPAL MANAGER OR AN ORIGINATOR State Form 49718 (R5 / 6-08) / Form LB 4 Approved by State Board of Accounts, 2008 CHECK ONE: PRINCIPAL MANAGER ORIGINATOR Date (MM/DD/YYYY): Registration Number Jurisdiction Registration Number Registration Number Information (if applicable). Use additional sheets if necessary. INITIAL APPLICATION RENEWAL APPLICATION Registration Number Registration Number Jurisdiction AMEND EXISTING REGISTRATION To amend, circle or identify item(s) being amended SURRENDER/CANCEL REGISTRATION Jurisdiction Jurisdiction ESTABLISH RELATIONSHIP TERMINATE RELATIONSHIP 1. INDIVIDUAL’S IDENTIFYING INFORMATION: (A) Last Name First Name Middle Name (B) Social Security Number Suffix (C) Gender Male (D) Date of Birth (MM/DD/YYYY) (E) State/Province of Birth Female (F) Country of Birth (G) List all names(s), other than your legal name, you have used or are using, or by which you are or were known since the age of 18. This field should include for example, nicknames, aliases, and names used before or after marriage. (Use additional sheets as necessary). Name Name Name Name (H) For amendments only: If this filing reports that an individual’s name has changed, enter the new name and attach supporting legal documentation: Last Name First Name Middle Name Suffix (I) Employer Name (Loan Broker): (J) Employer’s Principal Address (do not use a P.O. Box): Number & Street City If this address is your private residence, check this box. State/Province or Country Zip+4/Postal Code (K) Office of Employment Address (if different from 1(J)) (do not use a P.O. Box): If this address is your private residence, check this box. Number & Street City State/Province or Country Zip +4/Postal Code (L) Current Residence Address (if different from employment address in 1(K)): Number & Street City State/Province or Country Zip +4/Postal Code (M) Telephone Numbers and E-mail Address: Business Phone Home Phone E-mail Address: State Form 49718 (R5 / 6-08) / Form LB 4 Cell Phone (optional) Fax Line (optional) Page 5 of 10 American LegalNet, Inc. www.FormsWorkflow.com Applicant full legal name (last, first, middle): _____________________________________________________ 2. ACADEMIC INSTRUCTION & TESTING: COURSE VENDOR COURSE NAME DATE OF COMPLETION (month, day, year) NUMBER OF HOURS REMINDER: Attached a copy of the course’s certificate of completion. 3. CONSENT TO SERVICE OF PROCESS: Applicant hereby appoints the Secretary of State of Indiana., and the successors in such office, its attorney in the State of Indiana upon whom may be served any notice, process, or pleading in any action or proceeding against myself arising out of, or in connection with my conduct as a principal manager or an originator or out of violation of the laws of Indiana, and I do hereby consent that any such action or proceeding against me may be commenced in any court of competent jurisdiction and proper venue within Indiana by service of process upon said agent as if the undersigned was organized or created under the laws of Indiana and has lawfully been served with process in Indiana. IT IS REQUESTED THAT A COPY OF ANY NOTICE, PROCESS, OR PLEADING SERVED HEREUNDER BE MAILED TO: Full Legal Name of Agent Number & Street City State/Province or Country Zip +4/Postal Code 4. LOAN BROKER VERIFICATION: (A) ESTABLISH RELATIONSHIP To the best of my knowledge and belief, the person completing this form is applying for registration as principal manager or an originator or is registered as such. I have taken appropriate steps to verify the accuracy and completeness of the information contained in this application. I have provided the applicant the opportunity to review the information contained herein and the applicant has approved this information and signed the Individual Verification in Section 9 of this form. Effective Date (MM/DD/YYYY) Name of Loan Broker Signature of authorized party Print Name and title of authorized party (B) TERMINATE RELATIONSHIP I have taken appropriate steps to verify the accuracy and completeness of the information contained herein and with this application for termination of an individual registration. Effective Date (MM/DD/YYYY) Name of Loan Broker Signature of authorized party Print Name and Title of authorized party NOTE: ATTACH A SEPARATE DOCUMENT TO THIS APPLICATION EXLAINING REASONS FOR TERMINATION Loan Broker Verification must always be completed in full with ORIGINAL, manual signature. State Form 49718 (R5 / 6-08) / Form LB 4 Page 6 of 10 American LegalNet, Inc. www.FormsWorkflow.com Applicant full legal name (last, first, middle): _____________________________________________________ 5. RESIDENTIAL HISTORY (list residential history for previous ten (10) years, leaving NO gaps): From To Street Address City State or (MM/YYYY) (MM/YYYY) Province Zip + 4 Postal Code Country 6. EMPLOYMENT HISTORY (list employment history for previous ten (10) years, leaving NO gaps, and indicate whether the employment is financial service-related.): From To Employer Position Held City State or Country YES or (MM/YYYY) (MM/YYYY) (company name) Province NO? Use Additional Sheets as Necessary (Principal Manager Applicants must include a description of any relevant employment, including a detailed description of duties performed and the name and contact information for the person you reported to) State Form 49718 (R5 / 6-08) / Form LB 4 Page 7 of 10 American LegalNet, Inc. www.FormsWorkflow.com Applicant full legal name (last, first, middle): _____________________________________________________ 7. Other Business: Are you currently engaged in any other business either as a proprietor, partner, officer, director, employee, trustee, and agent or otherwise? (Please exclude non-financial services-related activity that is exclusively charitable, civic, religious, or fraternal and is recognized as tax exempt.) If YES, provide the following details: the name of the other business; whether the business is financial services-related; the address of the other business; the nature of the other business; your position, title, or relationship with the other business; the start date of your relationship; the approximate number of hours per month you devote to the other business; and briefly describe your duties relating to the other business. (Attach additional sheets as needed.) YES NO Details: 8. DISCLOSURES: Questions must be answered fully, and must include all actions or legal proceedings occurring in any court in any jurisdiction. If the answer to any of the questions is “YES”, provide complete details of all events or proceedings in an attachment, listing the offense, cause number, date of conviction, and the court in which the individual was convicted. Refer to the explanation of terms section of the instructions for explanations of italicized terms. Financial Disclosure YES NO (A) Within the past ten (10) years: (1) have you filed a personal bankruptcy petition or been the subject of an involuntary bankruptcy petition? (2) based upon events that occurred while you exercised control over any organization, have any filed a bankruptcy petition or been the subject of an involuntary bankruptcy petition? (B) Has a bonding company ever denied, paid out on, or revoked a bond for you? (C) Do you have any unsatisfied judgments or liens against you? Criminal Disclosure YES NO (D) Have you ever within the past five (5) years: (1) been convicted of or pled guilty or nolo contendere ("no contest") in a domestic, foreign, or military court to any felony? (2) been charged with any felony? (E) Based upon activities that occurred while you exercised control over it, has any organization ever within the past five (5) years: (1) been convicted of or pled guilty or nolo contendere ("no contest") in a domestic, foreign, or military court to any felony? (2) been charged with any felony? (F) (1) Within the past ten (10) years have you ever been convicted of or pled guilty or nolo contendere ("no contest") in a domestic, foreign, or military court to a crime involving: financial services or a financial services-related business; any fraud, false statements, or omissions; any theft or wrongful taking of property; bribery; perjury; forgery; counterfeiting; extortion; or a conspiracy to commit any of these offenses? (2) Are there pending charges against you for a crime as described in 8(F)(1)? (G) Based upon activities that occurred while you exercised control over it, has an organization ever: (1) been convicted of or pled guilty or nolo contendere ("no contest") in a domestic, foreign, or military court to a crime specified in 8(F)(1)? (2) been charged with a crime specified in 8(F)(1)? State Form 49718 (R5 / 6-08) / Form LB 4 Page 8 of 10 American LegalNet, Inc. www.FormsWorkflow.com Applicant full legal name (last, first, middle): _____________________________________________________ Regulatory Action Disclosure (H) Has any State or federal regulatory agency or foreign financial regulatory authority ever: (1) found you to have made a false statement or omission or been dishonest, unfair or unethical? (2) found you to have been involved in a violation of a financial services-related regulation(s) or statute(s)? (3) found you to have been a cause of a financial services-related business having its authorization to do business denied, suspended, revoked or restricted? (4) entered an order against you in connection with a financial services-related activity? (5) denied, suspended, or revoked your registration or license, disciplined you, or otherwise by order, prevented you from associating with a financial services-related business or restricted your activities? 6) barred you from association with an entity regulated by such commission, authority, agency, or officer, or from engaging in a financial services-related business? (7) issued a final order based on violations of any law or regulations that prohibit fraudulent, manipulative, or deceptive conduct? (I) Are you now the subject of any regulatory proceeding that could result in a "yes" answer to any part of 8(H)? Civil Judicial Disclosure (J) (1) Has any domestic or foreign court ever: (a) enjoined you in connection with any financial services-related activity? (b) found that you were involved in a violation of any financial services-related statute(s) or regulation(s)? (c) dismissed, pursuant to a settlement agreement, a financial services-related civil action brought against you by a State, federal, or foreign financial regulatory authority? YES NO YES NO YES NO (2) Are you named in any pending financial services-related civil action that could result in a "yes" answer to any part of 8(J)(1)? Customer Arbitration/Civil Litigation Disclosure (K) Have you ever been named as a respondent/defendant in a financial services-related consumer-initiated arbitration or civil litigation which: (1) is still pending; or (2) resulted in an arbitration award or civil judgment against you, regardless of amount, or that required corrective action; or (3) was settled for any amount? 9. INDIVIDUAL VERIFICATION: I solemnly swear or affirm under the penalties of perjury that: A. I have completed the academic instruction listed in Section 2, all courses are listed on the Division’s approved course list or I have attached evidence that the Commissioner has approved the course(s); B. I have not been convicted in any jurisdiction of a felony within the previous five (5) years or a crime involving fraud or deceit in the previous ten (10) years other then which is disclosed herein or on the attached documents; and C. the information appearing in this application form and the attached documents hereto is true, accurate, and complete to the best of my knowledge. Signature Title State Form 49718 (R5 / 6-08) / Form LB 4 Date (MM/DD/YYYY) Page 9 of 10 American LegalNet, Inc. www.FormsWorkflow.com PRINCIPAL MANAGER/ORIGINATOR APPLICATION CHECKLIST For Initial/Renewal Applicants: CHECK THE FOLLOWING ITEMS MUST BE COMPLETED OR ATTACHED TO THIS APPLICATION HERE $200.00 Principal Manager Application Fee or $100.00 Originator Application Fee plus $32.25 for an FBI background check Complete set of fingerprints on an FBI fingerprint card (FD258) Check whether applying for registration as a principal manager or an originator If applicable, listed your Individual Registration Number Completed Section 1: Individual’s Identifying Information, providing the following information: • Full legal name (Section 1(A)); • Social Security Number (Section 1(B)); • Date of Birth (Section 1(D)); • Full legal name of employer (Section 1(I)); • Principal address of employer (Section 1(J)); • If applicable, employment address (Section 1(K)); • Current Residence Address (Section 1(L)); and • Business & Home Telephone (Section 1(K)) Certificate(s) of completion for the academic instruction course(s) listed in Section 2 Completed Section 3: Consent to Service of Process An authorized party of the Loan Broker(s) has completed and signed Section 4: Loan Broker Verification Section 5: Residential History: provided the previous ten (10) years of residential history, leaving no gaps. Section 6: Employment History providing the following information: • Previous ten (10) years of employment history, leaving no gaps • Identified which employment was financial service-related • Principal Manager Applicants Only: attached a detailed description of relevant employment including a detailed description of the duties performed and the name and contact information for person you reported to, establishing that the applicant fulfills the three (3) year experience requirement. If answered “YES” to any questions in Section 7: Other Business and/or Section 8: Disclosures; have provided the required additional information. Signed and Dated the verification in Section 9: Individual Verification Any supporting documentation For Transfer Applicants: CHECK THE FOLLOWING ITEMS MUST BE COMPLETED OR ATTACHED TO THIS APPLICATION HERE If applicable, applicant’s Individual Registration Number Checked the “Amend Existing Relationship” box Completed Section 1: Individual’s Identifying Information, providing the following information: • Full legal name (Section 1(A)); • Full legal name of employer (Section 1(I)); • Principal address of employer (Section 1(J)); • If applicable, employment address (Section 1(K)); • Current Residence Address (Section 1(L)); and • Business & Home Telephone (Section 1(K)) Completed Section 4: • Authorized party of applicant’s new employer has completed and signed Section 4(A); • Authorized party of applicant’s previous employer has completed and signed Section 4(B); and • Previous employer has included additional documentation identifying reasons for termination. Completed and signed the Individual Verification in Section 9 The original certificate of registration being withdrawn State Form 49718 (R5 / 6-08) / Form LB 4 Page 10 of 10 American LegalNet, Inc. www.FormsWorkflow.com