Get California Statement Identity 2013-2024

STATE OF CALIFORNIA DEPARTMENT OF BUSINESS OVERSIGHT STATEMENT OF IDENTITY AND QUESTIONNAIRE DBO FS 512 SIQ Rev. 11-13 File Number if any Licensee Company Name Insert Department of Business Oversight file number if any and the name of the licensee company to which this Statement of Identity and Questionnaire relates. 45 of the California Penal Code or Section 781 of the California Welfare and Institution Code. Code attach a written declaration stating whether drugs were involved. injury Date of suit Location of court Have you ever changed your name including a woman s maiden name or ever been known by any name other than that herein listed If so explain. Change in name through marriage or court order and exact date of each name change must be listed. Prior Name Date of Name Change Have you ever done business under a fictitious firm name either as an individual or in any form of business e.g. partnership limited liability company corporation or other The following questions must be answered by all persons submitting this questionnaire in connection with an ESCROW AGENT S LICENSE. In what capacity will you be employed e.g. Clerk Escrow Officer Manager Officer Director etc. Do you expect to be a party to or broker or salesman in connection with escrows conducted by the escrow company which is employing you This statement will be considered confidential information and will be filed and maintained as part of the confidential records not subject to public inspection. VERIFICATION I the undersigned state that I am the person named in the foregoing Statement of Identity and Questionnaire that I have read and signed said Statement of Identity and Questionnaire and know the contents thereof including all exhibits attached thereto and that the statements made therein including any exhibits attached thereto are true and that I have not omitted any information needed to make this document true. This verification may be made either before a Notary Public or as a declaration under penalty of perjury. This form MUST be executed before a Notary Public if it is executed OUTSIDE the State of California. I certify/declare under penalty of perjury that the foregoing is true and correct. License Period License Number Type of License/Business Name and Address of Licensing Entity any such license ever been suspended revoked or surrendered subject to a settlement or any other similar action traffic citations that do not constitute a misdemeanor or felony offense Convicted includes a verdict of guilty by judge or jury a plea of guilty or of nolo contendere or a forfeiture of bail. All convictions must be disclosed even if the plea or verdict was thereafter set aside and the charges against you dismissed or expunged or if you have been pardoned. Convictions occurring while you were a minor must be disclosed unless the record of conviction has been sealed under Section 1203. 45 of the California Penal Code or Section 781 of the California Welfare and Institution Code. Code attach a written declaration stating whether drugs were involved. injury Date of suit Location of court Have you ever changed your name including a woman s maiden name or ever been known by any name other than that herein listed If so explain. Change in name through marriage or court order and exact date of each name change must be listed. Prior Name Date of Name Change Have you ever done business under a fictitious firm name either as an individual or in any form of business e.g. partnership limited liability company corporation or other The following questions must be answered by all persons submitting this questionnaire in connection with an ESCROW AGENT S LICENSE. In what capacity will you be employed e.g. Clerk Escrow Officer Manager Officer Director etc. Do you expect to be a party to or broker or salesman in connection with escrows conducted by the escrow company which is employing you This statement will be considered confidential information and will be filed and maintained as part of the confidential records not subject to public inspection. VERIFICATION I the undersigned state that I am the person named in the foregoing Statement of Identity and Questionnaire that I have read and signed said Statement of Identity and Questionnaire and know the contents thereof including all exhibits attached thereto and that the statements made therein including any exhibits attached thereto are true and that I have not omitted any information needed to make this document true. This verification may be made either before a Notary Public or as a declaration under penalty of perjury. B. Are you currently or have you been within the last ten years under federal state or local investigation for possible violation of any law ordinance or licensing or regulatory scheme Financial business means securities broker-dealer or agent investment adviser or investment adviser representative financial planner insurance agent escrow agent finance lender or broker mortgage lender or servicer real estate broker payday lender financial institution bill payer or prorater commodity sales person certified public accountant or any other business involving investment or financial transactions. License Period License Number Type of License/Business Name and Address of Licensing Entity any such license ever been suspended revoked or surrendered subject to a settlement or any other similar action traffic citations that do not constitute a misdemeanor or felony offense Convicted includes a verdict of guilty by judge or jury a plea of guilty or of nolo contendere or a forfeiture of bail. All convictions must be disclosed even if the plea or verdict was thereafter set aside and the charges against you dismissed or expunged or if you have been pardoned. Convictions occurring while you were a minor must be disclosed unless the record of conviction has been sealed under Section 1203. 45 of the California Penal Code or Section 781 of the California Welfare and Institution Code. Code attach a written declaration stating whether drugs were involved. injury Date of suit Location of court Have you ever changed your name including a woman s maiden name or ever been known by any name other than that herein listed If so explain. Change in name through marriage or court order and exact date of each name change must be listed. Prior Name Date of Name Change Have you ever done business under a fictitious firm name either as an individual or in any form of business e.g. partnership limited liability company corporation or other The following questions must be answered by all persons submitting this questionnaire in connection with an ESCROW AGENT S LICENSE. In what capacity will you be employed e.g. Clerk Escrow Officer Manager Officer Director etc. Do you expect to be a party to or broker or salesman in connection with escrows conducted by the escrow company which is employing you This statement will be considered confidential information and will be filed and maintained as part of the confidential records not subject to public inspection. VERIFICATION I the undersigned state that I am the person named in the foregoing Statement of Identity and Questionnaire that I have read and signed said Statement of Identity and Questionnaire and know the contents thereof including all exhibits attached thereto and that the statements made therein including any exhibits attached thereto are true and that I have not omitted any information needed to make this document true. .