ApplicationFormcopyallorganizationdocumentsrequiredfiledwiththeIllinoisSecretaryStateandcopythefilingassumedbusinessnamewiththeappropriateCountyClerk146sofficesole proprietorshipSupplementalApplic ID: 844807
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1 CILA License Application Check List Ap
CILA License Application Check List ApplicationFormcopyallorganizationdocumentsrequiredfiledwiththeIllinoisSecretaryStateandcopythefilingassumedbusinessnamewiththeappropriateCountyClerk’sofficesole proprietorship.SupplementalApplicationprovidedtheapplicationpacketandcreditreportof:proprietor,theapplicantindividualeverypartner,theapplicant AppointmentAttorneyFactforServiceProcessPhotographsboththeinsideandoutsidethe InformationFormprovidedapplicationpacketchecktheamount$450madepayabletheDirectortheDivisionFinancialInstitutions servelicensefee,onehalftheabovefeetheapplicationfiled ConsumerCreditSectionRandolph,Suite100 Chicago,60601 STATEILLINOISDEPARTMENTFINANCIALPROFESSIONALREGULATION DIVISIONFI
2 NANCIALINSTITUTIONSAPPLICATIONFORLICENSE
NANCIALINSTITUTIONSAPPLICATIONFORLICENSE CONSUMERINSTALLMENTLOANACTFinancial 1. Full Name of Applicant: 2. Proposed Licensed Location: (Address) (City) (County) (State) (Zip Code) 3. Corporate Address: (Address) (City) (State) (Zip Code) 4. ( ) Telephone # 5. ( ) Fax # 6. ContactPerson 7. FederalEmployerI.D. 8. Type of Ownership: Sole Proprietorship , Partnership , Corporation , Limited Liability Company , Other Incorporation: 10. IF Yes, provide a list of the States. 11. If Yes, provide full details on a separate sheet. 12. If Yes, provide full details on a separate sheet. 13. Date Number Office U
3 se Only Log No. Check # Fee Sl
se Only Log No. Check # Fee Slip CILA License Application Check List ApplicationFormcopyallorganizationdocumentsrequiredfiledwiththeIllinoisSecretaryStateandcopythefilingassumedbusinessnamewiththeappropriateCountyClerk’sofficesole proprietorship.SupplementalApplicationprovidedtheapplicationpacketandcreditreportof:proprietor,theapplicantindividualeverypartner,theapplicant AppointmentAttorneyFactforServiceProcessPhotographsboththeinsideandoutsidethe InformationFormprovidedapplicationpacketchecktheamount$450madepayabletheDirectortheDivisionFinancialInstitutions servelicensefee,onehalftheabovefeetheapplicationfiled ConsumerCreditSectionRandolph,Suite100 Chicago,60601 STATEILLINOISDEPAR
4 TMENTFINANCIALPROFESSIONALREGULATION DIV
TMENTFINANCIALPROFESSIONALREGULATION DIVISIONFINANCIALINSTITUTIONSAPPLICATIONFORLICENSE CONSUMERINSTALLMENTLOANACTFinancial 1. Full Name of Applicant: 2. Proposed Licensed Location: (Address) (City) (County) (State) (Zip Code) 3. Corporate Address: (Address) (City) (State) (Zip Code) 4. ( ) Telephone # 5. ( ) Fax # 6. ContactPerson 7. FederalEmployerI.D. 8. Type of Ownership: Sole Proprietorship , Partnership , Corporation , Limited Liability Company , Other Incorporation: 10. IF Yes, provide a list of the States. 11. If Yes, provide full details on a separate sheet. 12. If Yes, provide full details on a s
5 eparate sheet. 13. Date Number Off
eparate sheet. 13. Date Number Office Use Only Log No. Check # Fee Slip given Dated at , County of , State of , this day of A.D., 20 (Signature) (Title) (Signature) (Title) Subscribed and sworn to me in County, in the State of , this day of , A.D. , 20 (Seal) Notary Public My Commission Expires given Dated at , County of , State of , this day of A.D., 20 (Signature) (Title) (Signature) (Title) Subscribed and sworn to me in County, in the State of , this day of , A.D. , 20 (Seal) Notary Public My Commission Expires Page 1 of 2 STATEILLINOISDEPARTMENTFINANCIALPROFESSIONALREGULATION DIVISIONFINANCIALINSTITUTI
6 ONS CONSUMERCREDITSECTION SUPPLEMENTAL A
ONS CONSUMERCREDITSECTION SUPPLEMENTAL APPLICATION answersmustTYPED legiblyPRINTED questionsmustanswered. Individual’sName: (First)(Middle)(Last) CorporateTitle: PercentageOwnership: DateBirth: SocialSecurityNumber: BusinessAddress: ResidentAddress: TelephoneNumber: BusinessExperienceforpastten(10)yearsdescendingchronological Order:copyresumeforthesameperiodtimemaysubstituted satisfythisrequirement.) Years FromCompanyName: Company Address: Position Held: Principal Duties: Years FromCompanyName: Company Address: Position Held: Principal Duties: Years FromCompanyName: Company Address: Position Held: Principal Duties:
7 thepastyearshaveyoueverbeenconvict
thepastyearshaveyoueverbeenconvictedfelony? No yes,provideseparatesheetfulldetailsincludingsummary,the court,presidingjudge(s)andthetitleanddocumentnumber. Page 2 of 2 11. In the past 10 years have you been a party to any material litigation? Yes No document Subscribed and sworn to before me this day of , 20 Notary Public My Commission Expires: (NOTARY SEAL) STATE OF ILLINOIS DEPARTMENT OF FINANCIAL & PROFESSIONAL REGULATION Division of Financial Institutions LICENSEE BOND Consumer Installment Loan Act KNOW ALL MEN BY THESE PRESENTS, That Corporate or Company Name Street Address City/State and, Directorpersons for the payment
8 ourselves,firmly Witnessourhandsandseals
ourselves,firmly Witnessourhandsandsealsthis day of A.D. conditiontheaboveobligationsuchthattheaboveCorporateCompanyName December the Now,thesaid CorporateCompanyName shall, upon issuance of said license as aforesaid, faithfully conform to and abide by each and every provision of said Act and of all rules, regulations and directions lawfully made by the Director of Financial Institutions thereunder, and will pay to the State and to any person or persons from said obligors, under and by virtue of the provisions of said Act, then this obligation to be void, otherwise to remain in full force and effect. Corporate or Company Name By President, Owner or Partner By Secretary, Owner
9 or Partner Surety or Bonding Comp
or Partner Surety or Bonding Company By Illinois Attorney-in-Fact (Attach Power of Attorney) & PROCESS KNOW ALL MEN BY THESE PRESENTS: THAT Corporate or Company Name Street City does hereby appoint the County State InstitutionsofficialInstallmentagainstInstitutionsFinancialrevoked,Financial State of , On 20 (CORPORATE SEAL) By (President, Owner, Partner) By (President, Owner, Partner) CORP. FILE NUMBER IF OUT OF STATE Subscribed and sworn to before me this day of 20 Notary Public My Commission Expires NOTARY SEAL INFORMATION FORM Resident officer of the Licensed Entity. A. (Name)(Title)(PercentStock) (Address) (City) (State) (Zip Code) B.
10 (Name)(Title)(PercentStock) (Address)
(Name)(Title)(PercentStock) (Address) (City) (State) (Zip Code) C. (Name)(Title)(PercentStock) (Address) (City) (State) (Zip Code) (If more space is required attach a separate sheet) II.Address Director of the Licensed Entity. A. (Name)(Title)(PercentStock) (Address) (City) (State) (Zip Code) B. (Name)(Title)(PercentStock) (Address) (City) (State) (Zip Code) C. (Name)(Title)(PercentStock) (Address) (City) (State) (Zip Code) (If more space is required attach a separate sheet) III. Stockholder Owning 10% or More of Capital Stock or Any Owner/Partner of the Licensed Entity who is Not Listed Above. A. (Name)(PercentStock/Ownership) (Address) (Cit
11 y) (State) (Zip Code) B. (Name)(Pe
y) (State) (Zip Code) B. (Name)(PercentStock/Ownership) (Address) (City) (State) (Zip Code) C. (Name)(PercentStock/Ownership) morespacerequiredattachseparatesheet) StateIllinoisDepartmentFinancialProfessionalRegulation DivisionFinancialInstitutionsLicenseApplicationMaterialWaiverKNOWALLMENTHESEPRESENTS: THAT Corporate or Company Name Street City atteststhat currentlylicenseetheDepartmentandhaspreviouslysubmittedthefollowingcheckedinformation theDepartmenttheapplicationsuchlicenseewithinthelastyearsandtherehavebeenno materialchanges. IllinoisSecretaryState(SoS)organizationdocument(referenceSectionCILALicenseApplicationCheckList) TypeSoSorganizationdocument Suppleme
12 ntalApplication(s)andcredreport(s)(refer
ntalApplication(s)andcredreport(s)(referenceSectionCILALicense ApplicationCheckList) SupplementalApplications(s)andcreditreport(s)forONLYthefollowingofficers: Departmentwillusethiswaivercrossreferenceapplicablematerialsthenewapplicationfor licensure.submissionthiswaiverdoesnotprecludetheDirectorfromseekinganyrelevantor additionalinformationshemayfindnecessaryfromthesaidapplicantfortheinvestigationto determinewhetherthelicenseshallissued. State of , On 20 (CORPORATE SEAL) By (President, Owner, Partner) By (President, Owner, Partner) CORP. FILE NUMBER IF OUT OF STATE Subscribed and sworn to before me this day of 20 Notary Public My Commission Expires NOTA