Immigration Consultant Disclosure - California Secretary Of State

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State of California

Secretary of State

Immigration Consultant Disclosure

(Business and Professions Code section 22443.1)

There is no fee for filing the Immigration Consultant Disclosure form.

IMPORTANT - Read instructions before completing this form.

This Space For Filing Use Only

NAME AND CONTACT INFORMATION OF IMMIGRATION CONSULTANT

Name of Immigration Consultant

2. Date of Birth (MM/DD/YYYY)

Residence Address of Immigration Consultant

City

State

Zip Code

Business Address of Immigration Consultant

City

State

Zip Code

Residence Phone Number

6. Business Phone Number

(including area code)

CONVICTIONS

(All convictions must be disclosed including convictions dismissed under Penal Code section 1203.4 or 1203.4(a).)

Have you ever been convicted of a violation of Section 6126 or of Division 8, Chapter

YES

19.5 of the Business and Professions Code?

Have you ever been arrested or convicted of a crime, including a crime dismissed

YES

under Penal Code section 1203.4 or 1203.4a?

AGENT FOR SERVICE OF PROCESS OF IMMIGRATION CONSULTANT, IF ANY

Name of designated Agent for Service of Process

10. Street Address of designated Agent for Service of Process in California

City

State

Zip Code

EMPLOYER (BY A CORPORATION OR PARTNERSHIP ONLY) INFORMATION, IF ANY

(If the immigration consultant is employed by

a corporation or partnership, complete Items 11, 12 and 13. If the employer corporation or partnership has an agent for service of process, complete Item

14. If the agent is an individual, the agent must reside in California and both Items 14 and 15 must be completed. If the agent is a corporation, the agent

must have a current certificate pursuant to Corporations Code section 1505 on file with the California Secretary of State and only Item 14 must be

completed (leave Item 15 blank).)

11. Name of Employer Corporation or Partnership

12. Business Phone Number

(including area code)

13. Business Address

14. Name of Employer’s designated Agent for Service of Process

15. If an individual, Street Address of Employer’s designated Agent for Service of Process

City

State

Zip Code

16.