"Arkansas Licensee Change Form for Money Services" - Arkansas

Arkansas Licensee Change Form for Money Services is a legal document that was released by the Arkansas Securities Department - a government authority operating within Arkansas.

Form Details:

  • Released on August 1, 2010;
  • The latest edition currently provided by the Arkansas Securities Department;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Arkansas Securities Department.

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ARKANSAS SECURITIES DEPARTMENT
HERITAGE WEST BUILDING, SUITE 300
201 EAST MARKHAM
LITTLE ROCK, ARKANSAS 72201
If change of control,
ARKANSAS LICENSEE CHANGE FORM
submit fee of $1000.
FOR MONEY SERVICES
1.
Name of Licensee:
AR License Number:
2.
Name Change (Insert new entity name):
Attach the following documents:
1. Copies of all amendments to the documents of organization filed with the appropriate regulatory authority in the
state of organization, as well as copies of any documents issued by said regulatory authority granting approval of
said filing.
2. Copies of any documents issued by the Arkansas Secretary of State granting approval of the amendments, if
applicable.
3. Rider to the Surety Bond reflecting the name change.
3.
Use of Assumed or Fictitious Name (Insert DBA):
Attach the following documents:
1. Copy of the Registered Fictitious Name Certificate issued by the Arkansas Secretary of State granting authority to
conduct business under the fictitious name.
2. Rider to the Surety Bond reflecting the name change.
New or Corrected Address/Telephone Number/Fax Number (Provide rider to the Surety Bond reflecting the address change):
4.
List all new executive officers, directors, partners, and members and titles held. Authority to Obtain Information from
Outside Sources (Attachment B) is required for each new officer, director, partner, and member (attach addendum if
5.
necessary).
Name & Title
Principal Office Address
% Ownership
Name & Title
Principal Office Address
% Ownership
Name & Title
Principal Office Address
% Ownership
Name & Title
Principal Office Address
% Ownership
List all persons that have a 25% or greater equity interest not listed above. Authority to Obtain Information from Outside Sources
(Attachment B) is required for each new officer, director, partner, and member (attach addendum if necessary).
Name
Principal Office Address
% Ownership
Name
Principal Office Address
% Ownership
Name
Principal Office Address
% Ownership
Name
Principal Office Address
% Ownership
Revised August 2010
ARKANSAS SECURITIES DEPARTMENT
HERITAGE WEST BUILDING, SUITE 300
201 EAST MARKHAM
LITTLE ROCK, ARKANSAS 72201
If change of control,
ARKANSAS LICENSEE CHANGE FORM
submit fee of $1000.
FOR MONEY SERVICES
1.
Name of Licensee:
AR License Number:
2.
Name Change (Insert new entity name):
Attach the following documents:
1. Copies of all amendments to the documents of organization filed with the appropriate regulatory authority in the
state of organization, as well as copies of any documents issued by said regulatory authority granting approval of
said filing.
2. Copies of any documents issued by the Arkansas Secretary of State granting approval of the amendments, if
applicable.
3. Rider to the Surety Bond reflecting the name change.
3.
Use of Assumed or Fictitious Name (Insert DBA):
Attach the following documents:
1. Copy of the Registered Fictitious Name Certificate issued by the Arkansas Secretary of State granting authority to
conduct business under the fictitious name.
2. Rider to the Surety Bond reflecting the name change.
New or Corrected Address/Telephone Number/Fax Number (Provide rider to the Surety Bond reflecting the address change):
4.
List all new executive officers, directors, partners, and members and titles held. Authority to Obtain Information from
Outside Sources (Attachment B) is required for each new officer, director, partner, and member (attach addendum if
5.
necessary).
Name & Title
Principal Office Address
% Ownership
Name & Title
Principal Office Address
% Ownership
Name & Title
Principal Office Address
% Ownership
Name & Title
Principal Office Address
% Ownership
List all persons that have a 25% or greater equity interest not listed above. Authority to Obtain Information from Outside Sources
(Attachment B) is required for each new officer, director, partner, and member (attach addendum if necessary).
Name
Principal Office Address
% Ownership
Name
Principal Office Address
% Ownership
Name
Principal Office Address
% Ownership
Name
Principal Office Address
% Ownership
Revised August 2010
6.
Read the following questions carefully. If the answer is yes to any of the questions, attach a full written explanation.
Include names, dates, court name and address, case number, disposition, and judgment amounts. Do not include items
previously reported.
A.
Is/has any criminal, civil, or administrative charges been issued against the
( ) Yes, attach explanation
applicant for activities which involve a financial transaction(s) or fraud in
( ) No
the past ten years?
B.
Has the applicant been convicted of any felony in the past ten years?
( ) Yes, attach explanation
( ) No
C.
Has the applicant been convicted of a crime involving a financial
( ) Yes, attach explanation
transaction(s) or fraud in the past ten years?
( ) No
D.
Is/has the applicant ever been the subject of a bankruptcy, assignment for
( ) Yes, attach explanation
the benefit of creditors, receivership, conservatorship, or any similar
( ) No
proceeding?
E.
Has any other state or federal government agency denied the applicant a
( ) Yes, attach explanation
license for money services?
( ) No
F.
Is/has the applicant ever been the subject of any administrative action or
enforcement proceeding by any state or federal government agency
( ) Yes, attach explanation
involving fines, penalties, or the revocation or suspension of any business
( ) No
license, registration, or permit?
Signature of Authorized Person
Date
Print Name
Title
STATE OR COMMONWEALTH OF
COUNTY OR PARISH OF
personally came and appeared before me, the undersigned
(authorized person above)
notary, and declared under oath that he/she is the
of
(Title)
, that he/she is authorized to sign and submit the attached
(Name of Company)
application, and that all statements and representations made therein are true and correct to the best of
his/her knowledge, information, and belief.
Sworn and subscribed to before me on this
day of
20
.
Notary Public
Print Name of Notary Public
(Seal)
My Commission Expires:
Revised August 2010
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