Mortgage Broker Relocation Application - Mortgage Brokers and Loan Originators

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State of Montana Division of Banking and Financial Institutions P.O. Box 200546 Helena, MT 59620-0546 Phone (406) 841-2920 Fax (406) 841-2930 MORTGAGE BROKER RELOCATION APPLICATION I ,_______________________________, am licensed in the State of Montana as a mortgage broker. My mortgage broker license number is ________________. My previous employer was ____________________________, license #__________, a mortgage broker licensed in the State of Montana. I wish to relocate my license to: _______________________________ Mortgage Broker Entity/Sole Proprietor License # _______________________________________________ Mortgage Broker Designated Manager Name (Print) _______________________________________________ Mortgage Broker Designated Manager Name (Signature) _______________________________________________ Mortgage Broker Company Name (Print) _______________________________________________ Street Address _______________________________________________ City State Zip ______________________________ Phone _______________________________________________ Mortgage Broker Signature _______________________________________________ Mortgage Broker Name (Print) _______________________________________________ Street Address _______________________________________________ City State Zip Please include a relocation application fee of $50.00 payable to the State of Montana. Your application will not be processed without this fee Vers. 1.3 (12/07)

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