Arizona Department of Financial Institutions
FE-LC-AP-Non_Mortgage_Industry_Branch_Application
iRevised 05/04/16
State:
Telephone Number & Extension Fax Number
State:
Telephone Number & Extension Fax Number
Date:
A State employee may not intentionally or knowingly violate this section. A violation of this section is cause for disciplinary action or dismissal pursuant to the
Agency's adopted personnel policy.
This section does not abrogate the immunity provided by section 12-820.01 or 12-820.02
Notice to Applicant Pursuant to A.R.S. § 41-1030
An agency shall not base a licensing decision in whole or in part on a licensing requirement or condition that is not specifically authorized by statute, rule or
state tribal gaming compact. a general grant of authority in statute does not constitute a basis for imposing a license requirement or condition unless a rule
is made pursuant to that general grant of authority that specifically authorizes the requirement or condition.
This section may be enforced in a private civil action and relief nay be awarded against the State. The court may award reasonable attorney fees, damages
and all fees associated with the license application to a party that prevails in an action against the state for a violation of this section.
Non-Mortgage Industry Branch Application
4. Authorized Individual: I hereby certify that to the best of my knowledge, this application contains no
misrepresentations or omissions of material facts. An Owner/Officer/Member on file with our Department
must sign this form.
This application must be complete and legible
Commercial or
Residential Location
To the Superintendent of Financial Institutions:
1. Principal Licensed Location Information (found on principal license):
License Type: Principal License Number:
Exact Name of Licensee:
City: Zip Code:
Designated Branch Manager (Overseer or Contact Person):
Toll Free Number:
Toll Free Number:
Direct Telephone Number & Extension
3. Individual to contact regarding the processing of this branch:
Name: Title:
Address Line 1:
Address Line 2:
Branch office is Zoned as a (check one)
Zip Code:
Exact DBA / Trade name if applicable:
Address on your “Principal” license:
2. Hereby request permission to establish a branch office at the following location:
City:
Toll Free Number:
