*BRANCH APPLICATION*
DEBT MANAGEMENT SERVICE PROVIDERS
STATE OF MAINE
BUREAU OF CONSUMER CREDIT PROTECTION
35 STATE HOUSE STATION
AUGUSTA, MAINE 04333-0035
TELEPHONE: (207) 624-8527 FAX: (207) 582-7699
FOR OFFICE USE ONLY
DATE RECEIVED _________________________
In accordance with the provisions of 32 M.R.S.A.,
c. 80-A, the Debt Management Services Act, AMOUNT RECEIVED _____________________
application is hereby made for a branch registration to CREDIT CARD[ ] CHECK #: ____________
provide debt management services to Maine consumers.
CASH NUMBER___________________________
1. FULL TRADE NAME (including d/b/a): _________________________________________________________
2. Address and telephone number of branch location to be registered: __________________________________
_________________________________________________________________________________________
3. Address and telephone number of home office: __________________________________________________
_________________________________________________________________________________________
Home Office Registration Number: DMS______
4. Provide evidence of counselor certification for the branch’s counselors. (Within twelve months of employment of a
debt counselor, a debt management service provider must provide evidence that the counselor has been certified
by completing a course approved by the administrator; Title 32 MRSA §6174-B(1)).
5. A $50,000 surety bond must accompany each application. Have your bonding or insurance company complete the
enclosed bond form, and submit the completed form with this application. Make certain that the bond is effective
st
at least until December 31 of the year for which you are applying.
6. Attach a financial statement and any other information necessary to substantiate financial soundness of the
applicant(s) as required by 32- MRSA, § 6173 (2).
7. If different from that of the main office, identify the financial institution which will maintain the trust account used to
deposit of consumers' funds, and provide the account number: _______________________________________
__________________________________________________________________________________________
8. If different from main office, please provide a copy of a sample written contract to be used by your company. (A
sample contract that meets the law's requirements is enclosed with this registration package.)
9. List the name, address, telephone number and e-mail address of the contact person for the Maine Bureau of
Consumer Credit Protection regarding customer complaints: ________________________________________
__________________________________________________________________________________________
______________________________________________E-mail address:_______________________________
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10. List the name, address, telephone number and e-mail address of the contact person for the Maine
Bureau of Consumer Credit Protection regarding scheduling of periodic compliance examinations:
__________________________________________________________________________________________
______________________________________________E-mail address:________________________________
11. Enclose the proper registration fee (Make checks payable to "Treasurer, State of Maine"): $250.00
Maine law [5 M.R.S.A. §130 (1991)] requires assessment of $20.00 for any check returned by your bank
for insufficient funds.
Dated this __________________day of ___________________, 200________
Signature: __________________________________________________
Printed Name: _______________________________________________
Title: ______________________________________________________
FOLLOWING INITIAL REGISTRATION,
APPLICATIONS MUST BE RECEIVED
ON OR BEFORE DECEMBER 1ST OF EACH YEAR
TO APPLY TO CONDUCT BUSINESS BEGINNING JANUARY 1 ST OF THE FOLLOWING YEAR
ADDRESSED AS FOLLOWS:
US Postal Service MAIL: OVERNIGHT OR EXPRESS MAIL (other Currier):
BUREAU OF CONSUMER CREDIT PROTECTION BUREAU OF CONSUMER CREDIT PROTECTION
35 STATE HOUSE STATION 76 NORTHERN AVENUE
AUGUSTA, ME 04333-0035 GARDINER ME 04345
NOTICE REGARDING PUBLIC INFORMATION
This application is a public record for purposes of Maine’s Freedom of Access Law, 1 MRSA §401, et seq. Public records must be
made available to any person upon request. Information that you supply as part of this application (except your Social Security
number) is public information. Other licensing records to which this information may later be transferred are also considered public
records. Where permitted by law, your name, license number, mailing address and other information listed on this application may be
posted on the State’s website.
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