"Application for a Licence as a High-Cost Credit Grantor" - Manitoba, Canada

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 Application for a Licence as a High-Cost Credit Grantor
1.
Name of applicant: ____________________________________________________________________
2.
Business name or business style of applicant (if different from above):
____________________________________________________________________________________
3.
Physical address of location to be licensed:
Address
No
Street
City
Province
Postal Code
Phone Number: (
)
Ext.
Email address:
________________________________________
Fax Number: (
)
Website:
4.
Type of business entity:
 Sole proprietorship
 Partnership
 Corporation
 Other ____________________________________________________________________
specify
5.
Enter below the full legal names of all owners, partners, directors or officers. Attach list if necessary.
Name
Title
Business Address
No
Street
City
Province/State
Postal/Zip Code
Phone Number: (
)
Ext.
Email address
Fax Number: (
)
Name
Title
Business Address
No
Street
City
Province/State
Postal/Zip Code
Phone Number: (
)
Ext.
Email address
Fax Number: ( )
6. a) Does the applicant offer high-cost credit products? Yes  No 
If no, go to 6 b). If yes, complete the following:
In person  Telephone  Internet  Mobile Application
Through what means? (Check all that apply)
 Fax  Email  Other (specify) ________________________________________
b) Does the applicant arrange high-cost credit products? Yes  No 
If no, go to 6 c). If yes, complete the following:
How does the applicant communicate with borrowers when arranging their high-cost credit product? (Check all
In person  Telephone  Internet  Mobile Application  Fax  Email
that apply)
 Other (specify) ________________________________________
 Application for a Licence as a High-Cost Credit Grantor
1.
Name of applicant: ____________________________________________________________________
2.
Business name or business style of applicant (if different from above):
____________________________________________________________________________________
3.
Physical address of location to be licensed:
Address
No
Street
City
Province
Postal Code
Phone Number: (
)
Ext.
Email address:
________________________________________
Fax Number: (
)
Website:
4.
Type of business entity:
 Sole proprietorship
 Partnership
 Corporation
 Other ____________________________________________________________________
specify
5.
Enter below the full legal names of all owners, partners, directors or officers. Attach list if necessary.
Name
Title
Business Address
No
Street
City
Province/State
Postal/Zip Code
Phone Number: (
)
Ext.
Email address
Fax Number: (
)
Name
Title
Business Address
No
Street
City
Province/State
Postal/Zip Code
Phone Number: (
)
Ext.
Email address
Fax Number: ( )
6. a) Does the applicant offer high-cost credit products? Yes  No 
If no, go to 6 b). If yes, complete the following:
In person  Telephone  Internet  Mobile Application
Through what means? (Check all that apply)
 Fax  Email  Other (specify) ________________________________________
b) Does the applicant arrange high-cost credit products? Yes  No 
If no, go to 6 c). If yes, complete the following:
How does the applicant communicate with borrowers when arranging their high-cost credit product? (Check all
In person  Telephone  Internet  Mobile Application  Fax  Email
that apply)
 Other (specify) ________________________________________
List each high-cost credit grantor that provides the high-cost credit product that the applicant arranges, along
with its address, email, contact person, website, phone and fax number.
_________________________________________________________________________________________
Describe how the applicant arranges high-cost credit products provided by the high-cost credit grantor listed
above, including how all fees charged to borrowers in relation to the arrangement of high-cost credit product(s)
are calculated.
__________________________________________________________________________________________
__________________________________________________________________________________________
c) Does the applicant provide high-cost credit products? Yes  No 
If no, go to 6 d). If yes, complete the following:
How does the applicant communicate with borrowers when providing their high-cost credit product? (check all
In person  Telephone  Internet  Mobile Application  Fax  Email
that apply)
 Other (specify) ________________________________________
Cash  Cheque  Direct
How does the applicant advance funds to borrowers? (Check all that apply.)
Deposit  Cash Card  Mobile Application  On-line Transfers  Other
specify)_______________________________
How does the applicant accept repayment of high-cost credit products? (Check all that apply.)
Cash  Cheque  Pre-authorized debit  Cash Card  Other (specify) __________________________
d) Does the applicant assist another to offer, arrange or provide high-cost credit products in any way that
Yes  No 
is not described at 6 b)?
If no, go to 7. If yes, complete the following:
List each high-cost credit grantor that offers, arranges or provides the high-cost credit products, along with its
address, phone and fax number and contact person.
_________________________________________________________________________________________
_________________________________________________________________________________________
In what way does the applicant provide assistance? (Check all that apply.)
 Making high-cost credit products information available to the public, including by means of the Internet
 Making equipment or other means available to the public, including Internet access, by which they may
obtain information about the high-cost credit products
 Assisting the public by any means, including by the Internet, to obtain the high-cost credit product
 Assisting borrowers to access money provided under the high-cost credit agreement
 Assisting borrowers to repay the high-cost credit product, including by cash card or other device
 Other (specify) _______________________________________________________
7. The applicant maintains records at the following address(es)________________________________________
_________________________________________________________________________________________
8. Has the applicant or any of the persons named in section 5 been convicted of an offence under any federal,
provincial, territorial or state law, or are any charges pending?
 No
 Yes Provide specifics:
_________________________________________________________________________________________
_________________________________________________________________________________________
9. Has the applicant or any of the persons named in section 5 been an undischarged bankrupt or been involved as
owner, director or officer of any firm or business that declared bankruptcy during the period of their
involvement?
 No
 Yes Provide specifics:
____________________________________________________________________________________
____________________________________________________________________________________
10. Has the applicant or any of the persons named in section 5 ever had a licence issued under this Act, or by an
authority responsible for issuing licences with respect to lending money in any jurisdiction, which has been
suspended or cancelled, or has the applicant ever applied for a renewal of such a licence and the renewal was
refused?
 No
 Yes Provide specifics:
___________________________________________________________________________________
___________________________________________________________________________________
11. Contact Person: Provide the name of an officer or employee who resides in Manitoba and who is authorized to
provide information requested by the director and to receive and disseminate information given by the director.
Name
Title
Business Address
No
Street
City
Province
Postal Code
Phone Number
Ext.
Business Email address
Fax Number
THE APPLICANT DECLARES THAT THE APPLICANT IS FAMILIAR WITH MANITOBA’S CONSUMER PROTECTION LEGISLATION IN
RESPECT OF HIGH-COST CREDIT PRODUCTS AND UNDERTAKES TO COMPLY WITH THIS LEGISLATION.
IT IS A CONDITION OF ANY LICENCE THAT THE CONSUMER PROTECTION OFFICE MUST BE ADVISED WITHIN 14 DAYS OF ANY
.
CHANGES TO INFORMATION IN, OR IN SUPPORT OF, THIS APPLICATION
STATUTORY DECLARATION
I/We declare that the information and statements in this application, and all information provided in support of this application, are complete and
true.
(Corporate seal, if any) _____________________________________________
Per:_________________________________
(printed name and title)
(signature)
_____________________________________________
Per:_________________________________
(printed name and title)
(signature)
Declared before me at ________________________
In the province/state of _______________________
This _______ day of ____________ 20______
Signature of a Commissioner for Oaths ________________________________ in and for the Province/State of_________________________
My commission expires on the ______________________ day of __________________________, 20___
If the statutory declaration is made outside Manitoba, make sure that the person it is declared before has the authority to do so for a
document to be used in Manitoba.
Every section in this form must be completed. Additionally, the following information must be included with the application. Please see
the attached document “High-Cost Credit Grantor Application Requirements” for more information about these items.
i. Articles of Incorporation or Business Name Registration
ii. Completed Sample Information Disclosure Document for each high-cost credit product offered, arranged or provided
by the applicant
iii. Completed Sample High-Cost Credit Agreement for each high-cost credit product offered, arranged or provided by the
applicant
iv. Criminal Record Check for the applicant and for each individual listed in section 5
v. Annual Licence Fee
vi. Manitoba Borrowers’ Financial Literacy Fund Levy
The applicant will provide any additional information requested by the Director of the Consumer Protection Office.
If you have questions about this application, please call the Consumer Protection Office at (204) 945-3800, or toll free in Manitoba 1-800-782-
0067.
Return to:
Director, Consumer Protection Office
Department of Justice
302 – 258 Portage Avenue
Winnipeg, MB R3C 0B6
NO REFUND OF THE FEE WILL BE MADE ONCE A HIGH-COST CREDIT GRANTOR LICENCE HAS BEEN ISSUED.
Privacy Notice: The personal information we collect is necessary to consider this application for a licence and to administer and enforce The
Consumer Protection Act, and is limited to the minimum amount necessary for these purposes. The personal information is being collected under
the authority of The Consumer Protection Act and clauses 36(1)(a) and (b) of The Freedom of Information and Protection of Privacy Act of
Manitoba and it is protected by The Freedom of Information and Protection of Privacy Act. If you have questions about the collection of this
personal information, please contact the Manager of Licensing at 302- 258 Portage Ave, Winnipeg, Manitoba, R3C 0B6, or by phone at (204) 945-
3800, or toll-free in Manitoba at 1-800-782-0067.
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