Initial License Application

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					                                       Commonwealth of Massachusetts
                                                         DIVISION OF BANKS

                             1000 Washington Street, 10th Floor, Boston, MA 02118-2218

                                         Initial License Application
       (This application should be used the first time a company applies to the Division for a license. A company should use the
     Supplementary Application for each additional location applied for under the same Federal Employer Identification Number.)


                                             This application must be typed.

License type(s) applied for (check all that apply):

Insurance Premium Finance Company
Motor Vehicle Sales Finance Company
                                                  See “Application Addendum for Finance Companies”
Retail Installment Sales Finance Company
Small Loan Company

Check Casher                                      See “Application Addendum for Check Cashers”

Foreign Transmittal Agency
                                                  See “Application Addendum for Money Transmitters”
Check Seller

Debt Collector                                    Debt Collector license applicants must complete Form DC1

Mortgage Lender                                   Mortgage Lender and Mortgage Broker license applicants must complete Form
Mortgage Broker                                   MU1 and Form MU2.

1. Federal Employer Identification Number (not a Social Security Number*):
*Individuals must use Federal Employer Identification Numbers obtained from the IRS, not Social Security Numbers.

2. Form of organization of applicant:
Individual doing business under own name
Individual doing business under an assumed name (d/b/a)*
Partnership
Corporation
Corporation doing business under an assumed name (d/b/a)*
LLC
Other (Describe)

*Applicants operating under an assumed name: Submit evidence of certification with city/town where business is located.

2a. Corporations: State of Incorporation/Organization:                                          Date:

Enclose a signed copy of the Articles of Organization or Certificate of Incorporation. If applicable, also submit a Foreign Corporation
Certificate signed by the Massachusetts Secretary of State or LLC filing with the Massachusetts Secretary of State.

3.     Full exact name of person, corporation, partnership, sole-proprietorship, or other entity, for which application is made:


3a. d/b/a (if applicable):




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4.   Mailing address (to send licenses, invoices, renewal applications, etc.)

Send correspondence attention to:


Address:                                                                                    Room #


City/Town                                                        State:                     ZIP:


Telephone: (      )                             Fax: (       )                              E-Mail



5.   Name of individual responsible for responding to all questions relating to this application.

Name of company/firm if other than Applicant (i.e., law firm, affiliate company, etc.)


Send correspondence attention to:


Address:                                                                                    Room #


City/Town                                                        State:                     ZIP:


Telephone: (      )                             Fax: (       )                              E-Mail



6.   Individual responsible for responding to consumer complaints regarding the applicant:

Name:


Address:                                                                                    Room #


City/Town                                                        State:                     ZIP:


Telephone: (      )                             Fax: (       )                              E-Mail



7.   Location where relevant books, records, accounts and documents are available for inspection and examination by the
     Commissioner of Banks:

Name of Company:
Company/Affiliate Location                         Other (attorney’s office, record keeping company, etc.)
Contact:                                                                                     Title:


Address:                                                                                    Room #


City/Town                                                        State:                     ZIP:


Telephone: (      )                             Fax: (       )                              E-Mail


Applicants who wish to maintain records outside of the Commonwealth of Massachusetts or to maintain records in forms other than
hard copy under the provisions of 209 CMR 48.00 must complete a RECORD KEEPING PLAN and must obtain prior written
approval of the Commissioner. Note: check cashers and foreign transmittal agencies are not authorized to maintain records out of
state.

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8.    Attorney or agent in Massachusetts on whom lawful process may be served:

Name:

Address:                                                                                        Room #


City/Town                                                           State:                      ZIP:


Telephone: (        )                             Fax: (       )                                E-Mail



9.    List the names and business addresses of senior Officers and Directors of the applicant in an addendum to the application.
      Include the positions of chief executive and or operating officer, president, executive or senior vice president, secretary,
      treasurer, or positions with similar responsibilities.

Name of President/CEO:

Business Address:                                                                               Room #


City/Town                                                           State:                      ZIP:


Telephone: (        )                             Fax: (       )                                E-Mail



10. For each individual in Question #9 and the manager of the location listed in Part III, provide a credit report dated within
    thirty (30) days prior to date of the application, and a resume or an up-to-date summary of professional experience
    including employers, dates of employment, and relevant business and educational experience. Credit reports must include
    a detailed explanation of any adverse reporting and evidence of third party settlement or resolution. Officers or Directors
    of publicly traded companies are not required to provide credit reports.

11. Provide three letters of professional reference, including at least one from a bank. Publicly traded companies are excepted.

12. List the names, business and home addresses, and percentage of stock held by stockholders holding or controlling, directly
    or indirectly, 10% or more of the voting stock of the applicant. Provide recent credit reports for those individuals. If the
    applicant has fewer than 20 stockholders, list them all (if such persons are corporations, trusts, or other entities, trace the
    ownership back to the individuals). If the applicant is a partnership, list the names, business addresses, and partnership
    interest (%) of all partners. If a trust, list all beneficiaries.

13. Does the applicant have any parent companies, subsidiaries, or affiliates?

Yes                                                  No

If yes, list all affiliates of the applicant, including full exact name(s) of parent companies and subsidiaries, and their principal lines of
business in an addendum. Also submit a chart which diagrams all parent/subsidiary relationships and ownership percentage of all
affiliates.

14. Does the applicant have one or more branches, parent companies, subsidiaries, or affiliates operating in the
    Commonwealth?

Yes                                                  No

If yes, list the names, addresses and relationship to the applicant in an addendum.




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15. Does the applicant intend to conduct business with Massachusetts consumers from more than one location?

Yes                                                No

If yes, complete the Supplementary Application for Additional Locations form for each location.

16. Has the applicant or any of its parent companies, subsidiaries, affiliates, senior officers (including the location manager
    listed in Part III), directors, principal stockholders/partners, or beneficiaries (of a trust) ever applied for a license from the
    Commissioner of Banks, or any other state agency, to do business in the Commonwealth?

Yes                                                No

If yes, what types were approved? Include license number(s).

17. Is the applicant, or any of its parent companies, subsidiaries, affiliates, senior officers (including the location manager
    listed in Part III), directors, principal stockholders, or beneficiaries (of a trust) licensed to conduct business in any state
    other than Massachusetts for the types of activity applied for in Part I?

Yes                                                No

If yes, forward the enclosed certification forms to each state and include a copy of each with the application.

18. Has the Commissioner of Banks, any other agency in the Commonwealth, any federal agency, or any agency of any
    other state ever denied, suspended, or revoked the license or registration of the applicant, any of its parent companies,
    subsidiaries, affiliates, senior officers (including the location manager listed in Part III), directors, principal
    stockholders/partners, or beneficiaries (of a trust) to engage in any regulated activity?

Yes                                                No

If yes, provide complete details in an addendum to this application. The information should include the following: name of agency,
date of action, and reason for action.

19. Has any governmental or regulatory agency ever initiated an informal or formal regulatory action or order against the
    applicant, or any of its parent companies subsidiaries, affiliates, senior officers (including the location manager listed in
    Part III), directors, principal stockholders/partners, or beneficiaries (of a trust)?

Yes                                                No

If yes, provide complete details in an addendum to this application. The information should include the following: name of agency,
date of action, and reason for action.

20. Has the applicant, any of its parent companies, subsidiaries, affiliates, senior officers (including the location manager listed
    in Part III), directors, principal stockholders/partners, or beneficiaries (of a trust) ever been enjoined or restrained by order
    of any court from engaging in any conduct or practice related to the arranging or extension of credit, collection of debt,
    transmission of money, cashing of checks, or any other financial activity?

Yes                                                No

If yes, provide complete details in an addendum to this application.




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NOTE: The following two questions differ from previous applications. Please read carefully.

21. In the past ten years, has the applicant, any of its parent companies, subsidiaries, affiliates, senior officers, directors,
    principal stockholders/partners, beneficiaries (of a trust) or any other person responsible for the management of the
    licensed location regardless of title, had any criminal proceeding filed against him/her/it that resulted in any finding
    other than “not guilty” for, a felony or any misdemeanor, including, but not limited to, motor vehicle violations, in the
    Commonwealth of Massachusetts or in any other jurisdiction?

Yes                                               No

If yes, provide complete details in an addendum to this application.

22. Is the applicant, any of its parent companies, subsidiaries, affiliates, senior officers, directors, principal
    stockholders/partners, beneficiaries (of a trust) or any other person responsible for the management of the licensed
    location regardless of title currently a party to any pending criminal proceeding?

Yes                                               No

If yes, provide complete details in an addendum to this application.

THE WORDS “CRIMINAL PROCEEDING” COVER ALL FELONIES AND ANY MISDEMEANOR, INCLUDING, BUT NOT
LIMITED TO, MOTOR VEHICLE VIOLATIONS.

FAILURE TO FULLY AND COMPLETELY DISCLOSE REQUIRED CRIMINAL BACKGROUND INFORMATION
REQUESTED IN THE TWO PREVIOUS QUESTIONS MAY RESULT IN LICENSE DENIAL.


Be advised: The Division has been authorized by the Criminal History Systems Board to
access Criminal Offender Record Information.

23. Has the applicant, any of its parent companies, subsidiaries, affiliates, senior officers (including the location manager listed
    in Part III), directors, principal stockholders/partners, or beneficiaries (of a trust) ever filed for protection under the U.S.
    Bankruptcy Code?

Yes                                               No

If yes, provide complete details in an addendum to this application.

24. Does the applicant have a web site?

Yes                                               No

If yes, provide address:

Indicate type (check only one):   Informational                  Interactive                      Transactional


Part II.           Financial Information (Please refer to appropriate addenda for
                   additional requirements.)
25. Submit financial statements for the prior two fiscal years. Unaudited statements, prepared in accordance with generally
    accepted accounting principles ("GAAP"), are acceptable. This information must include both statements of condition
    and income and expense (profit and loss) statements. In addition, submit entity only audited or unaudited financial
    statements, prepared in accordance with GAAP, dated within 90 days of date of application.




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26. Submit current and two prior years’ financial statements for the parent, principal stockholders, directors & officers of
    any corporation with fewer than twenty (20) stockholders, partners, or beneficiaries (of a trust) of the applicant. If
    unaudited, current statements for all entities must be completed in accordance with GAAP, signed under the pains and
    penalties of perjury, and dated not more than 90 days prior to the date of application. Individuals may use the
    FINANCIAL FORM. Prior two years’ financial statements for all entities must be completed in accordance with GAAP,
    include statements of condition and income and expense, include all supporting schedules, and be signed under the
    pains and penalties of perjury, if unaudited.

27. Provide a list of pending litigation against the applicant. Include potential settlement amounts that could significantly
    affect the applicant's financial position.

Not applicable

28. Does the applicant have any contingent liabilities as an endorser, guarantor, or otherwise?

Yes                                               No

If yes, provide complete details in an addendum to this application.

29. Submit a list of lines of credit, showing name of creditor, total amount of line, amount of line outstanding, and
    expiration date. Submit a list of all other available funding sources.


Part III.           Location Information

30. Location where business is to be conducted (complete the Supplementary Application for each additional location):

Address:                                                                                  Room #


City/Town                                                       State:                    ZIP:


Telephone: (        )                           Fax: (      )                             E-Mail



31. Individual responsible for managing the applicant’s business at the above location:

Name of Manager:

Business Address:                                                                         Room #


City/Town                                                       State:                    ZIP:


Telephone: (        )                           Fax: (      )                             E-Mail




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Part IV.               Certification & Notarization
32. Pursuant to Massachusetts General Law chapter 62C, §49A, I hereby certify under the pains and penalties of perjury that I,
    to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law.




By:
          Signature of Individual (non-corporations) or Corporate Officer

Submit a "Certificate of Good Standing" (corporations) or a "Letter of Compliance" (individuals, partnerships, trusts, and Officers
and Directors of new corporations) from the MA Department of Revenue. Note: Corporations located outside the Commonwealth
must obtain a Foreign Corporation Certificate to qualify for a "Certificate of Good Standing".

33. Notarization



I,                                                                               , a duly authorized officer of
          Name



                                     (applicant)

certify under the pains and penalties of perjury that all statements above, or attached hereto, are true to the best of my knowledge
and belief.




                    (signature of applicant or authorized officer)

On this                 day of               , before me, the undersigned notary public, personally appeared the above named




proved to me through satisfactory evidence of identification, which was to be the person whose name is signed on the preceding
document, and acknowledged to me that he/she signed it voluntarily for its stated purpose.



Before me

My Commission Expires:

           (Seal)                                                                   Notary Public




Rev. 01/03/06

June 27, 2010




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