Fillable Arizona Department of Financial Institutions (Arizona)

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Arizona Department of Financial Institutions (Arizona)

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Arizona Department of Financial Institutions
100 North 15th Avenue, Suite 261
Phoenix, AZ 85007
1 of 5
FE-LC-FM-DFI_Biographical_Statement
Revised 0
Title/Position:
Individual's Full Legal Name:
Alias(es) Nicknames, or changes in name:
Place of Birth:
AzDFI License# (if applicable):
License Type:
Licensee/Applicant Name:
DFI Biographical Statement
There must be an answer provided for each inquiry. If not applicable use “None” or “n/a”.
Do not leave any blank spaces.
1. Identifying Information
State:
City:
Date of Birth:
Residential Address:
E-mail Address:
Mobile Telephone Number:
Business Telephone Number:
Social Security No.:
City:
State:
Zip Code:
To:
From:
Address:
From:
Address:
City:
State:
Zip Code:
To:
Show all residences for the past ten (10) years in chronological order with the most recent first. Attach additional pages if
necessary.
From:
Address:
From:
2. Residence Information
Address:
City:
State:
Zip Code:
City:
State:
Zip Code:
To:
City:
State:
Zip Code:
To:
To:
From:
Address:
Arizona Department of Financial Institutions
100 North 15th Avenue, Suite 261
Phoenix, AZ 85007
2 of 5
FE-LC-FM-Biographical_Statement
Revised 0
Supervisor:
A. Employment History:
Show every employment you have had and all periods of employment for the past ten (10) years in chronological order
with the most recent first. Operating your own business is considered employment, please list that information. You must
include complete addresses. Resumes or personal references are not accepted in lieu of completing this form (include
current position). Attach additional pages if necessary.
3. Employment Information
Address of Employer:
Reason for Leaving:
Supervisor:
From:
Name of Employer:
Address of Employer:
To:
Name of Employer:
Reason for Leaving:
Supervisor:
Position/Title:
Reason for Leaving:
To:
From:
Name of Employer:
Name of Employer:
Address of Employer:
Reason for Leaving:
Supervisor:
From:
Name of Employer:
Address of Employer:
To:
Address of Employer:
To:
Position/Title:
From:
Reason for Leaving:
Supervisor:
Position/Title:
Position/Title:
To:
Position/Title:
From:
Arizona Department of Financial Institutions
100 North 15th Avenue, Suite 261
Phoenix, AZ 85007
3 of 5
FE-LC-FM-DFI_Biographical_Statement
Revised 
(c) in the past ten years dismissed, pursuant to a settlement agreement, a financial
services-related civil action brought against the applicant by a State or foreign
financial regulatory authority?
(a) in the past ten years enjoined the individual in connection with any financial
services-related activity?
(b) in the past ten years found the individual to be in violation of any financial services-
related statute(s) or regulation(s)?
(g) Is the individual named in any pending financial services-related civil action that could
result in a "yes" answer to any part of (f)?
(1) been convicted of or pled guilty or nolo contendere ("no contest") in a domestic,
foreign, or military court to any felony?
4. Disclosures
(b) In the past ten years has the individual:
(1) found the individual to have made a false statement or omission or been dishonest,
unfair or unethical?
(1) been convicted of or pled guilty or nolo contendere ("no contest") in a domestic,
foreign, or military court to a misdemeanor involving: financial services or a financial
services-related business; any fraud, false statements, or omissions; any theft or
wrongful taking of property; bribery; perjury; forgery; counterfeiting; extortion; or a
conspiracy to commit any of these offenses?
(2) been charged with a misdemeanor specified in 4(B)(1)?
(a) Has the individual ever:
(2) been charged with any felony?
B. Regulatory Action Disclosure
(c) In the past ten years, has any State or federal regulatory agency or foreign financial
C. Civil Judicial Disclosure
(d) Has the individual’s authorization to act as an attorney, accountant, or State or federal
contractor ever been revoked or suspended?
(e) Is the individual now the subject of any regulatory proceeding that could result in a "yes"
answer to any part of 4(C)?
(f) Has any domestic or foreign court:
(2) found the individual to have been involved in a violation of a financial services-
related regulation(s) or statute(s)?
(3) found the individual to have been a cause of a financial services-related business
having its authorization to do business denied, suspended, revoked or restricted?
(4) entered an order against the individual in connection with a financial services-related
activity?
(5) denied, suspended, or revoked the individual’s registration or license or otherwise,
by order, prevented it from associating with a financial services-related business or
restricted its activities?
If the answer to any of the following is “YES”, provide complete details of all events or proceedings in an
attachment, including as applicable; name and location of court, docket or case number, and status and
summary of event or proceeding; copies of applicable charge(s), order(s), and/or consent agreement(s). Refer
to the explanation of terms section of the instructions for explanations of italicized terms. Remember to file
updates of these disclosures as needed.
A. Criminal Disclosure
YES
NO
Arizona Department of Financial Institutions
100 North 15th Avenue, Suite 261
Phoenix, AZ 85007
4 of 5
FE-LC-FM-DFI_Biographical_Statement
Revised 
Signature of individual: ________________________________
(j) Does the individual have any unsatisfied judgments or liens against them?
(i) Has a bonding company ever denied, paid out on, or revoked a bond for the individual?
(h) In the past ten years has the individual been the subject of a bankruptcy petition?
D. Financial Disclosure
(d) I authorize all my current and former employers , law enforcement agencies, and any other person to furnish to any jurisdiction ,
or any agent acting on its behalf, any information they have, including without limitation my creditworthiness, character, ability,
business activities, educational background, general reputation, history of my employment and, in the case of former employers ,
complete reasons for my termination;
(e) I have read and understand applicable federal and state law, and will be in compliance at all times;
(f) I promise to keep the information contained in this form current and to file accurate supplementary information on a timely basis;
Date (MM/DD/YYYY) ______________
5. Affidavit:
(c) I understand that I am subject to administrative, civil or criminal penalties if I give false or misleading answers;
(a) I have read and understand the items and instructions on this form;
(b) My answers (including attachments) are true and complete to the best of my knowledge;
Arizona Department of Financial Institutions
100 North 15th Avenue, Suite 261
Phoenix, AZ 85007
5 of 5
FE-LC-FM-DFI_Biographical_Statement
Revised 0
DFI Biographical Statement Checklist
Biographical Statement
Background Check: Required for Control persons, Active Managers and Responsible Individuals.
Control persons are individuals whom directly or indirectly own 20% (15% for money transmitters)
or more of the voting shares of the applicant. (see application instructions)
Letter of explanation and all applicable documents for any Disclosure question that was marked
"Yes".
Did You Remember To:
Answer ALL blanks, questions or statements AND if not applicable entered "NONE" or “N/A”
Legibly print or type all information on all documents
Staple each individual set of forms together
Properly label attachments to correspond with the applicable document and document inquiry
Sign all documents where applicable
Make copies for your records
Include all documents required before submitting application packet
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Arizona Department of Financial Institutions (Arizona)

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Completed 20 July 2020

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