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

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The application for a licensee seeking an
				  additional location license pursuant to Financial Code Section
				  23005(c)
				  shall be filed upon the form set forth in subdivision (c) of this section. An
				  applicant under this section must currently hold a valid deferred deposit
				  transaction license pursuant to Financial Code Section
				  23005(a).
(b) Within 20 calendar days from the receipt
				  of the application under this rule, the Commissioner shall inform the
				  applicant, in writing, that the application is complete and accepted for
				  filing, or that the application is deficient and specify what information is
				  required to complete the application. Within 15 calendar days from the filing
				  of a completed application, the Commissioner shall reach a decision on the
				  license.
(c) An application for a
				  license as set forth in subdivision (a) shall be submitted to the Commissioner
				  on the following form:
(Department of Corporations Use Only)
DEPARTMENT OF CORPORATIONS
Fee Paid $___________________________
File
							 No.___________________________
Receipt No.___________________________
STATE OF CALIFORNIA DEPARTMENT OF
					 CORPORATIONS
"SHORT FORM APPLICATION" FOR A LICENSE UNDER THE
					 CALIFORNIA DEFERRED DEPOSIT TRANSACTION LAW (LICENSEE CURRENTLY HAVING ONE OR
					 MORE LICENSED LOCATIONS)
________________________________________________________________________________________
This application must be accompanied by a fee of $300 which
					 includes an application fee of $200, and an investigation fee of $100, both of
					 which are non-refundable. (Financial Code Section
					 23006.) The
					 application (together with the fees payable to the Department of Corporations)
					 must be filed only in the Sacramento office of the Department of Corporations,
					 located at 1515 K Street, Suite 200, Sacramento, California 95814.
________________________________________________________________________________________
1. Name of applicant:
				  ____________________________________________________________________
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).)
2. Applicant's licensed place of business
				  will be located at (Financial Code Section
				  23020):
____________________________________________________________________________
(Number and
							 Street)
(City)
(State)
(Zip)
___________________________
(Telephone number)
(Fax number)
Provide the following additional information for any mobile
					 unit location:
___________________________
(Manufacturer) (Model) (Year) (Color) (Vehicle
					 Identification No. (VIN))
__________________________________________________________________________
(License Plate No.)
(Applicant Identifier (if
							 any))
Proposed area in which the mobile unit will
					 operate:
3. The FULL first,
				  middle (if no middle name, so indicate) and last name of the individual in
				  charge of this location.
_________________________________________________________________________
*
(First Name)
(Middle
							 Name)
(Last Name)
(*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.))
4. Please indicate by marking the appropriate
				  box if there has been or will be ANY CHANGE in the applicant's plan of business
				  previously submitted to the Department of Corporations.
___________________________
[ ] Yes (please explain)
___________________________
___________________________
[ ] No
5. Please provide license number and address
				  of one other California Deferred Deposit Transaction license held by this
				  applicant.
File # _______________ Address
					 ______________________________
6. Please provide the name, address, title,
				  telephone number, and email address (if applicable) of the person to contact
				  regarding this application. The license will also be mailed to this person
				  unless otherwise instructed.
Attention:_____________________________________________________________________
(Name)
(Title)
(Telephone
							 Number)
_______________________________________________________________________________________________________
(Number and
							 Street)
(City)
(State)
(Zip Code)
Email
							 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.
___________________________
(Applicant)
Executed at ___________________________
___________________________
(Signature of Declarant)
Date ___________________________
___________________________
(Typed Name)
___________________________
(Title)