APPLICATION FOR APPROVAL OF LOAN BROKER ACADEMIC INSTRUCTION COURSE State Form 53272 (R2 / 4-08) Approved by State Board of Accounts, 2007 PLEASE READ CAREFULLY: YOU MUST SUBMIT THE FOLLOWING: • • • • • • Non-refundable initial application fee of $400 and $25 per credit hour above six (6) credit hours Non-refundable renewal application fee of $400 and $25 per credit hour above six (6) credit hours For a live course: application, script or detailed presentation notes, timeline of course (how much instruction time will be spent on each topic), course book, and any materials to be distributed For a video course: application, script of video, copy of video, timeline of course (how much instruction time will be spent on each topic), course book, and any materials to be distributed For a correspondence course: application, time line of course (how much time would the average student spend on each topic), course book, and any materials to be distributed For an on-line course: application, script of presentation if streaming audio, print-out of each screen, timeline of course (how much instruction time will be spent on each topic), and any supplemental materials This application and submission is for the approval of the named course ONLY. Each course must be submitted individually. You may request a certain number of credit hours. However, determination of credit hour approval will be based on time of actual instruction with length of lecture and length of materials considered. Twenty-four (24) hour courses must consist of live instruction and contain at least one (1) hour of instruction on Indiana loan broker law and at least two (2) hours of instruction on federal loan broker law. Approval of each course is for ONE YEAR. To renew a course approval, you must submit a properly completed application, the renewal application fee, and all course material, with all changes from the previously approved version clearly marked. 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 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. Submit this properly completed application and the supporting course material to the following address: Indiana Secretary of State Securities Division 302 W. Washington St., Room E – 111 Indianapolis, Indiana 46204 State Form 53272 (R2 / 4-08) Page 1 of 5 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 APPROVAL OF LOAN BROKER ACADEMIC INSTRUCTION COURSE State Form 53272 (R2 / 4-08) Approved by State Board of Accounts, 2007 Date (MM/DD/YYYY) Initial Application Renewal Application 1. VENDOR INFORMATION: (A) Full Legal Name (B) Name of Contact Person (C) Address of Vendor (D) City (E) State (F) Zip+4/Postal Code (G) Telephone Number (H) Fax Number (I) E-Mail Address for Contact Person (J) Web Address of Vendor 2. COURSE INFORMATION: (A) Title of Course (B) Target Audience (C) Has the Securities Commissioner previously approved this course? If Yes, when: (D) Type of Course In-house (one company only) (E) Method of Presentation (Please check one) State Form 53272 (R2 / 4-08) No Open to any company or individual Live Correspondence (F) Student Evaluation (Please check all that apply Assignments or Worksheets Yes Video On-Line Final Exam Quizzes Other: Page 2 of 5 American LegalNet, Inc. www.FormsWorkflow.com 3. TO BE COMPLETED IF A LIVE COURSE: (A) Total Minutes of Instruction (Excludes break, meal, and test time) (B) Description of Materials Distributed (Check all that apply) Course Book Power Point Notes Other (describe in detail): (C) Is the site for this course accessible to persons with disabilities? Yes No 4. TO BE COMPLETED IF A VIDEO COURSE: (A) Total Minutes of Instruction on Video (B) Proctor or Leader in Room: (C) Description of Materials Distributed (check all that apply) Course Book Power Point Notes Other (describe in detail): 5. TO BE COMPLETED IF A CORRESPONDENCE COURSE: (A) Total Pages of Material (B) Description of Materials Distributed (check all that apply) Course Book Other (describe in detail): 6. TO BE COMPLETE IF AN ON-LINE COURSE: (A) Total Minutes of Timed Script (Example would be if streaming audio component included) (B) Total Pages of Text (Example would be if each screen was printed) (C) Description of Materials Distributed (check all that apply) Course Book Other (describe in detail): REST OF PAGE INTENTIONALLY LEFT BLANK State Form 53272 (R2 / 4-08) Page 3 of 5 American LegalNet, Inc. www.FormsWorkflow.com 7. COURSE INSTRUCTOR(S) INFORMATION (To be completed if a live or video course): (A) Full Legal Name of Instructor: First Name Last name Middle name Street address City State Zip+4/Postal Code Principal Occupation Within the past ten (10) years have you been subject to a disciplinary proceeding? YES NO Within the past five (5) years have you been convicted of or plead guilty or nolo contendere (“no contest”) in a domestic, foreign, or military court to any felony? YES NO Within the past ten (10) years have you been subject to a disciplinary proceeding? YES NO Within the past five (5) years have you been convicted of or plead guilty or nolo contendere (“no contest”) in a domestic, foreign, or military court to any felony? YES NO Within the past ten (10) years have you been subject to a disciplinary proceeding? YES NO Within the past five (5) years have you been convicted of or plead guilty or nolo contendere (“no contest”) in a domestic, foreign, or military court to any felony? YES NO (B) Full Legal Name of Instructor: First Name Last name Middle name Street address City State Zip+4/Postal Code Principal Occupation (C) Full Legal Name of Instructor: First Name Last name Middle name Street address City State Zip+4/Postal Code Principal Occupation SUBMIT A RÉSUMÉ FOR EACH COURSE INSTRUCTOR, USE ADDITIONAL FORMS AS NEEDED State Form 53272 (R2 / 4-08) Page 4 of 5 American LegalNet, Inc. www.FormsWorkflow.com 8. ACKNOWLEDGMENTS (A) I acknowledge that the Securities Commissioner may request additional information in consider the approval of this course; (B) I acknowledge that this course will be/is open to the Indiana Secretary of State, Securities Division for observation; (C) I affirm, under penalties for perjury, that the representation made in this application and in the attached documents hereto are true, accurate, and complete to the best of my knowledge. Printed Name and Title Signature Date (MM/DD/YYYY) REST OF PAGE INTENTIONALLY LEFT BLANK State Form 53272 (R2 / 4-08) Page 5 of 5 American LegalNet, Inc. www.FormsWorkflow.com