California Code of Regulations
Title 10 - Investment
Chapter 3 - Commissioner of Financial Protection and Innovation
Subchapter 13 - Deferred Deposit Transaction Law
Article 1 - Applications
Section 2021 - Short Form Application for Deferred Deposit Transaction Licensee Seeking Additional Location License; Form

Fictitious Business Name: _____________________________________________________-

(If the applicant will be doing business under a fictitious business name that has not been previously provided to the Department of Corporations, provide a copy of the Certificate of Filing and Proof of Publication, both of which bear the County Clerk's filing stamp. Refer to Section 17000 of the Business and Professions Code for the requirements of filing this statement. (Financial Code Section 23023).)

Provide the following additional information for any mobile unit location:

___________________________

(Manufacturer) (Model) (Year) (Color) (Vehicle Identification No. (VIN))

Proposed area in which the mobile unit will operate:

(*Furnish a Statement of Identity and Questionnaire, form enclosed (Financial Code Section 23008), along with a fingerprint card obtained from the Department of Corporations and the cost of fingerprint processing. (Financial Code Section 23006). If a Statement of Identity and Questionnaire has already been provided to the Department of Corporations for this individual, there is no need to provide another form. (Financial Code Section 23008.) Check cashers that held a valid permit prior to January 1, 2003 issued pursuant to Civil Code Section 1789.37, that have been making deferred deposits prior to January 1, 2003 and that have fingerprint information on file with the Department of Justice, must provide a Statement of Identity and Questionnaire but do not need to provide new fingerprint cards for persons who already have their cards on file with the Department of Justice. (Financial Code Section 23100.))

___________________________

[ ] Yes (please explain)

___________________________

___________________________

[ ] No

File # _______________ Address ______________________________

In the event of the issuance of a license, applicant agrees to comply with the requirements of the California Deferred Deposit Transaction Law and rules adopted, and orders issued, by the Commissioner of Corporations, and further agrees that in the event of any change of its officers, directors, or any persons named in this application, that an amendment to the application reflecting such change shall within sixty (60) days from the date of the change, be filed with the Commissioner of Corporations setting forth the change, the effective date of the change, the names of the persons involved in the change, and a statement of the qualifications of each successor person. (Financial Code Sections 23008, 23010.) Applicant acknowledges that the Short Form Application supplements the information provided in the original application for a license under the California Deferred Deposit Transaction Law. (Financial Code Section 23005(b) & (c).)

WHEREFORE, applicant requests that a license be issued by the Commissioner of Corporations authorizing applicant to engage in business under the California Deferred Deposit Transaction Law within the State of California.

The applicant has duly caused this application to be signed on its behalf by the undersigned, thereunto duly authorized.

The undersigned, on behalf of the applicant, acknowledges that this application and all exhibits thereto which are not designated as confidential are subject to public inspection pursuant to Section 250.9.1, Chapter 3, Title 10, California Code of Regulations. A request for confidentiality of certain documents may be requested pursuant to Section 250.10. If a request for confidential treatment is granted (or denied), the person making such request will be notified in writing.

I declare under penalty of perjury that I have read the foregoing application, including all exhibits attached thereto, or filed therewith, and know the contents thereof, and that the statements therein are true and correct.