California Code of Regulations › Title 10 - Investment › Chapter 3 - Commissioner of Financial Protection and Innovation › Subchapter 2.3 - Capital Access Companies › Article 2 - Application for Licensure and Related Forms › Section 280.151 - Application for a License Under the Capital Access Company Law

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The application for licensure under the Capital Access
					 Company Law shall be made in the following form:
(Department of Corporations Use
							 Only)
DEPARTMENT OF CORPORATIONS
Fee Paid $___________________________
File No.___________________________
Receipt No.___________________________
STATE OF CALIFORNIA DEPARTMENT OF CORPORATIONS FACING
					 PAGE FOR APPLICATION FOR A LICENSE UNDER THE CAPITAL ACCESS COMPANY
					 LAW
PRE-LICENSE AMENDMENT
							 NO.
___________________________
POST-LICENSE AMENDMENT
							 NO.
___________________________
The application
must be TYPEWRITTEN and
					 accompanied
by an application fee of $1,400. The application (together
					 with the fee payable to the Commissioner of Corporations) must be filed only in
					 the Sacramento Office of the Department of Corporations.
Special Instructions:
Any amendment to this
					 application for licensure under the Capital Access Company Law shall be made by
					 a verified pre-license or post-license amendment to the application. A
					 pre-license amendment is required for an amendment to the application prior to
					 licensure; a post-license amendment is required subsequent to licensure. An
					 amendment is made by filing the completed "Facing Page" with the appropriate
					 pre-license or post-license amendment number entered, attaching the pages of
					 that part of the application (including the exhibits) that are revised or
					 changed, and attaching another duly executed and verified "Execution Page".
					 (The Execution Page is found at the end of this application.)
1. Name of Applicant:
				  ___________________________
Fictitious Business Name:
					 ___________________________
2. List the place or places of business at
				  which Applicant will engage in licensed activity. Indicate principal place of
				  business and branch or other office locations: (Attach a separate sheet, if
				  necessary.)
___________________________
(Number and
							 Street)
(City)
(County)
(State)
(Zip)
___________________________
___________________________
("d.b.a." or fictitious business name)
(Name of person in charge of business location)
3.
				  Applicant is organized and will do business as (check as applicable):
[ ] a corporation
[ ] a limited
							 liability company
[ ] a partnership
[ ] a limited
							 partnership
[ ] trust
[ ] other (please
							 specify) _________________________
4.
				  Complete the following:
Applicant was organized on
					 ____________________(Date).
The
FULL
first, middle (if no middle name, so
					 indicate) and last name, and complete business address MUST be given for each
					 person named below: (Attach additional sheets, if necessary.)
General Partners:
___________________________
(Name)
(Business Address)
___________________________
(Name)
(Business Address)
___________________________
(Name)
(Business Address)
President/Chief Executive
					 Officer:
___________________________
(Name)
(Business Address)
Executive Vice President/Vice
					 President:
___________________________
(Name)
(Business Address)
Secretary:
___________________________
(Name)
(Business Address)
Treasurer/Chief Financial
					 Officer:
___________________________
(Name)
(Business Address)
Other Principal
					 Officers:
___________________________
(Name)
(Business Address)
___________________________
(Name)
(Business Address)
___________________________
(Name)
(Business Address)
Director(s):
___________________________
(Name)
(Business Address)
___________________________
(Name)
(Business Address)
___________________________
(Name)
(Business Address)
Manager(s)/Member(s)
[i.e., a
					 manager member of an association, or a manager appointed or elected by the
					 members of a limited liability company]:
___________________________
(Name)
(Business Address)
___________________________
(Name)
(Business Address)
___________________________
(Name)
(Business Address)
Trustee(s):
___________________________
(Name)
(Business Address)
___________________________
(Name)
(Business Address)
___________________________
(Name)
(Business Address)
Employees who have access to or
					 responsibility for funds held by the applicant:
___________________________
(Name)
(Business Address)
___________________________
(Name)
(Business Address)
___________________________
(Name)
(Business Address)
Any person (other than those persons listed
					 above) that owns or controls, directly or indirectly, the power to direct, or
					 cause the direction of, the management and policies of the applicant. If the
					 "person" is a corporation or other business entity, please provide sufficient
					 information to identify the individual(s) in positions of management in, or who
					 own or control, the corporation or business entity. (E.g., the name and
					 business address of the officers, directors, partners, etc.) (See Corporations
					 Code Sections
					 28035
					 and
					 28036):
___________________________
(Name)
(Business Address)
___________________________
(Name)
(Business Address)
5.
				  Provide the following information for the investment adviser(s) who will make
				  recommendations to the applicant with respect to the investment of funds.
a..
___________________________
(Name)
(Business Address)
___________________________
(Name)
(Business Address)
___________________________
(Name)
(Business Address)
b.
				  Provide the following information for each investment adviser:
1. Is the investment adviser registered under
				  the Investment Advisers Act of 1940?
[ ] Yes. The investment adviser's SEC File Number:
					 ____________________
[ ] No. Explain why and cite the appropriate statutory
					 authority. (E.g., the investment adviser is exempt from registration under
					 Section 203(b)(1) of the
					 Investment Adviser Act of 1940.).
2. Is the investment adviser licensed by the
				  State of California?
[ ] Yes. The investment adviser's license number:
					 _________________________
[ ] No. Explain why and cite the appropriate statutory
					 authority. (E.g., the investment adviser is exempt from licensure under Section
					 25202 of the Corporate Securities
					 Law of 1968.)
___________________________