Form ADM 10 Application for License - Texas

Form ADM10 is a Texas Office of Consumer Credit Commissioner form also known as the "Application For License". The latest edition of the form was released in July 1, 2016 and is available for digital filing.

Download a PDF version of the Form ADM10 down below or find it on Texas Office of Consumer Credit Commissioner Forms website.

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Print Form
Print Form
Application for License
Regulated Industry
Ownership
License Status
Application
Structure
(License will be:)
Type
CHECKLISTS AND INSTRUCTIONS FOR COMPLETING APPLICATIONS ARE PROVIDED ON THE OCCC WEBSITE. ENSURE YOU READ
ALL CHECKLISTS, INSTRUCTIONS, AND ADMINISTRATIVE RULES BEFORE COMPLETING AND SUBMITTING YOUR APPLICATION.
Section 1: Identifying Information
FEIN (Federal Employment Identification Number), or
Entity Name or Name of Owner/Sole Proprietor
SSN (Social Security Number) of Owner/Sole Proprietor
Is the applicant seeking a credit access business license or
motor vehicle sales finance license, and does the applicant
Operating Name (d/b/a)
conduct business with consumers through branch offices or
-
other business locations?
Transfer License Number(if applicable)
Yes
No
If "Yes", complete the appropriate form below for each location:
Mailing Address
CAB10 - Branch location (for Credit Access Business license applications)
No. of Branch Locations for this Application
Texas
MV-61 - Registered Offices (for Motor Vehicle Sales Finance license applications)
No. Registered Offices for this Application
City
State
Zip Code
Location Address
Location Phone Number
Texas
Location Fax Number
City
State
Zip Code
County
Website Address
Name of Location Manager
Section 2: Main Office Contact Information
Contact Information for Application
Compliance Officer
Name
Name
Title
Title
Email Address
Email Address
Business Phone Number
Business Phone Number
Fax Number
Fax Number
The Office of Consumer Credit Commissioner obtains information from this form and certain third-party sources. With few exceptions, you
may review and correct the information we collect. To find out more about the information we collect or to make an open records
request, contact our Public Information Officer at 512-936-7622 or public.information@occc.texas.gov.
Office of Consumer Credit Commissioner Licensing-512-936-7605 or licensing@occc.texas.gov
Page 1 of 3
Form ADM10 (Rev 7/16)
Print Form
Print Form
Application for License
Regulated Industry
Ownership
License Status
Application
Structure
(License will be:)
Type
CHECKLISTS AND INSTRUCTIONS FOR COMPLETING APPLICATIONS ARE PROVIDED ON THE OCCC WEBSITE. ENSURE YOU READ
ALL CHECKLISTS, INSTRUCTIONS, AND ADMINISTRATIVE RULES BEFORE COMPLETING AND SUBMITTING YOUR APPLICATION.
Section 1: Identifying Information
FEIN (Federal Employment Identification Number), or
Entity Name or Name of Owner/Sole Proprietor
SSN (Social Security Number) of Owner/Sole Proprietor
Is the applicant seeking a credit access business license or
motor vehicle sales finance license, and does the applicant
Operating Name (d/b/a)
conduct business with consumers through branch offices or
-
other business locations?
Transfer License Number(if applicable)
Yes
No
If "Yes", complete the appropriate form below for each location:
Mailing Address
CAB10 - Branch location (for Credit Access Business license applications)
No. of Branch Locations for this Application
Texas
MV-61 - Registered Offices (for Motor Vehicle Sales Finance license applications)
No. Registered Offices for this Application
City
State
Zip Code
Location Address
Location Phone Number
Texas
Location Fax Number
City
State
Zip Code
County
Website Address
Name of Location Manager
Section 2: Main Office Contact Information
Contact Information for Application
Compliance Officer
Name
Name
Title
Title
Email Address
Email Address
Business Phone Number
Business Phone Number
Fax Number
Fax Number
The Office of Consumer Credit Commissioner obtains information from this form and certain third-party sources. With few exceptions, you
may review and correct the information we collect. To find out more about the information we collect or to make an open records
request, contact our Public Information Officer at 512-936-7622 or public.information@occc.texas.gov.
Office of Consumer Credit Commissioner Licensing-512-936-7605 or licensing@occc.texas.gov
Page 1 of 3
Form ADM10 (Rev 7/16)
Application for License (Continued)
Section 3: Owners and Principal Parties
Proprietorships: Include spouses with community property interest.
Limited Partnerships, Corporations, & Other Entities: Provide ownership information as required by:
7 TAC, §83.302 (Regulated Lenders),
7 TAC, §84.602 (Motor Vehicle Sales Finance),
General Partnerships: Provide names of all general partners regardless of
7 TAC, §85.202 (Pawn Shops), or
percentage of ownership
7 TAC, §89.302 (Property Tax Lender)
If additional space is needed, attach a document identifying all required information noted below.
Owners: Proprietors, Partners, Members, or Stockholders
Name
% of Ownership
Name
% of Ownership
Name
Name
% of Ownership
% of Ownership
Name
% of Ownership
Name
% of Ownership
Name
Name
% of Ownership
% of Ownership
Principal Parties
Officers
President
Vice President
Secretary
Treasurer
Other
Other
Directors
Name
Name
Name
Name
Name
Name
Name
Name
Name
Other Principal Parties (Members, Managers, Etc)
Name
Name
Name
Name
Name
Name
Office of Consumer Credit Commissioner-Licensing-512-936-7605 or licensing@occc.texas.gov
Form ADM10 (Rev 7/16)
Page 2 of 3
Application for License (Continued)
Section 4: Disclosure Questions
If the answer to any of the below questions is "YES", provide a summary of each event or proceeding and copies of relevant
documents as an attachment.
(A) Has the entity or control affiliate ever:
YES
NO
1) been convicted of or pled guiltyor nolo contendre ("no contest") to a felony in a domestic, foreign, or military court; or
2) been charged with any felony?
(B1) During the past ten (10) years, has the entity or control affiliate been convicted of or pled guilty or nolo contendre in a
domestic, foreign, or military court to committing or conspiring to commit a misdemeanor involving: financial services or a
financial services related business, fraud, false statements, theft or wrongful taking of property, bribery, perjury, forgery,
counterfeiting, or extortion?
(B2) Are there pending charges against the entity or a control affiliate for a misdemeanor specified in (B1)?
(C) In the past ten (10) years, has any state, federal, or foreign regulatory agency ever:
1) found the entity or a control affiliate to have made a false statement or omission or been dishonest, unfair, or unethical;
2) found the entity or a control affiliate to have been involved in a violation of a financial services related regulation(s) or
statute(s);
3) found the entity or a control affiliate to have been the cause of a financial services related business having its
authorization to do business denied, suspended, revoked or restricted;
4) entered an order against the entity or control affiliate in connection with a financial services related activity; or,
5) denied, suspended, or revoked the entity's or a control affiliate's registration or license or otherwise, by order, prevented it
from associating with a financial services related business or restricted its activities?
(D) Has the entity's or a control affiliate's authorization to act as an attorney, accountant, or state or federal contractor ever
been revoked or suspended?
(E) Is the entity or a control affiliate now the subject of any regulatory proceeding that could result in a "yes" answer to any part
of Section C(4)?
(F1) Has any domestic or foreign court in the past ten (10) years:
a) enjoined the entity or control affiliate in connection with any financial services related activity;
b) found the entity or a control affiliate to be in violation of any financial services related statute(s) or regulation(s); or
c) dismissed, pursuant to a settlement agreement, a financial services related civil action brought against the applicant or
control affiliate by a state or foreign financial regulatory authority?
(F2)Is the entity or a control affiliate named in any pending financial services related civil action that could result in a "yes"
answer to any part of (F1)?
(G) Has a bonding company ever denied, paid out on, or revoked a bond for the entity?
(H) Does the entity have any unsatisfied judgments or liens against it?
The following questions are to be answered by Pawnshop License Applicants only.
(I) If applicant intends to deal in firearms, has applicant applied for or obtained a Federal Firearms License?
(J) Within what municipal jurisdiction is the shop to be located?
(K) If the application is for a new pawnshop license, provide the straight-line distance from the proposed location to the nearest operating
pawnshop. (Be exact)
The undersigned affirms that all answers made in the application for license, disclosure of owners and principal parties, application questionnaire and disclosure questions, and in all supporting
schedules and exhibits are true, correct, and complete and are made for the purpose of securing the license(s) indicated here. The applicant is of good moral character, good business repute, and
possesses the character and general fitness necessary to warrant belief that the applicant will operate the business lawfully and fairly within the provisions of the Texas Finance Code. FALSE OR
MATERIALLY INCOMPLETE ANSWERS ARE GROUNDS FOR DENIAL.
Signature
Title
Date
Signature
Title
Date
Office of Consumer Credit Commissioner - Licensing-512-936-7605 or licensing@occc.texas.gov
Form ADM10 (Rev 7/16)
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