Fillable IL LB FORM 15-10 Application for Registration as (Illinois Secretary of State)

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IL LB FORM 15-10 Application for Registration as (Illinois Secretary of State)

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Illinois Secretary of State
Securities Department
421 E. Capitol Ave., 2nd Floor
Springfield, IL 62701
217-782-2256
IL LB FORM 15-10
Application for Registration
as a Loan Broker
1. Name of Applicant (if an individual or sole proprietor, state last name, first name and middle name):
2. Social Security Number or F.E.I.N.:
3. Telephone Number:
4. Name under which Loan Broker business primarily is conducted, if different:
5. Firm’s Main Address (If P.O. Box, must have legal address.): Include Addresses of all Branch Offices in Illinois on an additional sheet.
6. Contact Person:
7. Date and Place Applicant obtained Legal Status:
Type of Legal Status:
❏ Corporation
❏ Partnership
❏ Sole Proprietorship
❏ Limited Liability Company
❏ Limited Liability Partnership
8. If Sole Proprietor, full Residence Address and Social Security Number:
9. If at the time of this filing, the Applicant is succeeding to the business of a currently registered Loan Broker:
a. Date of Succession: ___________________________________________________________________________________________
b. Name of Predecessors:_________________________________________________________________________________________
c. IRS Employer Identification Number: ______________________________________________________________________________
Printed by authority of the State of Illinois. November 2015 — 100 — SEC 327.2
Application to register with the Office of the Illinois Secretary of State, Securities Department, pursuant to the Illinois Loan Brokers Act of 1995.
Street Address (LEGAL)
City, State, ZIP
Street Address (MAILING, IF DIFFERENT)
City, State, ZIP
Name
Fax Number
Business Telephone Number
Email Address
Date of Formation State of Formation
Street Address
City, State, ZIP
Social Security Number
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10. Nature and Place(s) of Business of the Applicant or Employment History (if an individual) for the past 10 years or for the period of
existence if less than 10 years:
11. Background Information — For the purposes of this section only, Applicant also includes principals, officers, directors, partners, members,
trustees, managers or any similar individual. Mark each question “yes” or “no.” If the answer to any question is “yes,” provide a detailed
explanation and/or documentation on an additional sheet.
a. In the past 10 years has the Applicant been convicted of or pleaded guilty or nolo contendre (no contest) in a domestic or foreign court to:
1. A felony or misdemeanor involving: investment, financial, loan broker or related business fraud, false statement, or omissions,
wrongful taking of property, or bribery, forgery, counterfeiting or extortion:
❏ Yes ❏ No
2. Any felony (other than listed above):
❏ Yes ❏ No
b. Has any domestic or foreign court in the past 10 years enjoined the applicant in connection with investment, financial or business
related activity:
❏ Yes ❏ No
c. Has any other federal regulatory agency, state regulatory agency or foreign financial regulatory authority:
1. Ever found the applicant to have made a false statement or omission, or been dishonest, unfair or unethical?
❏ Yes ❏ No
2. Ever found the applicant to have been involved in a violation of investment, business or financial regulations or statutes?
❏ Yes ❏ No
3. Ever found the applicant to have been a cause of a loan broker, investment or financial related business having its
authorization to do business denied, suspended, revoked, restricted or otherwise adversely affected?
❏ Yes ❏ No
4. In the past 10 years, entered an order against the applicant in connection with an investment, financial or loan broker related activity?
❏ Yes ❏ No
5. Ever denied, suspended, revoked or otherwise adversely affected the applicant’s registration or license, prevented it from
associating with an investment, financial or loan broker related business, or otherwise disciplined it by restricting its activities?
❏ Yes ❏ No
6. Ever revoked, suspended or otherwise adversely affected the applicant’s license as an attorney or accountant?
❏ Yes ❏ No
d. Has any foreign government, court or regulatory authority ever entered an order against the applicant related to financial activity or
fraud other than as reported above?
❏ Yes ❏ No
e. Is the applicant now the subject of any proceeding that could result in a “yes” answer to any parts of Section 11?
❏ Yes ❏ No
f. Has a bonding company denied, paid out on or revoked a bond for the applicant?
❏ Yes ❏ No
g. Does the applicant have any material unsatisfied judgements or liens against it?
❏ Yes ❏ No
12. Name, Residence, Business Address and 10-year occupational statement for each principal of the Applicant. (If a Corporation, provide
information for all officers, directors or other persons with similar positions. If a Sole Proprietorship, Partnership, Limited
Partnership, Limited Liability Company, Unincorporated Association, Limited Liability Company or any similar form of business organization,
provide information for those person(s) who may legally bind the organization. For more space, attach additional sheets.)
10-Year Occupational History:
10-Year Occupational History:
10-Year Occupational History:
Signature
Name and Title (type or print)
Date Name of Applicant
Name
Business Street Address
Social Security Number
Home Street Address
City, State, ZIP City, State, ZIP
Name
Business Street Address
Social Security Number
Home Street Address
City, State, ZIP City, State, ZIP
Name
Business Street Address
Social Security Number
Home Street Address
City, State, ZIP City, State, ZIP
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IL LB FORM 15-10 Application for Registration as (Illinois Secretary of State)

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Completed 28 August 2020

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