Form Cacl 280.153 Notice Of Officers, Directors, Partners, "Control" Persons, Managers, Members, Trustees And Employees Of A Capital Access Company - California Department Of Corporations

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Fee: $20.00 + DOJ Noncriminal Applicant Fingerprint Fee
(Fees should include the Department of Corporations’ filing fee of [$20.00]
and the fee charged by the Department of Justice [Penal Code Section 11105]
for processing Noncriminal Applicant Fingerprints.)
Receipt No.__________________
STATE OF CALIFORNIA
DEPARTMENT OF CORPORATIONS
NOTICE OF
OFFICERS, DIRECTORS, PARTNERS, “CONTROL” PERSONS, MANAGERS, MEMBERS,
TRUSTEES AND EMPLOYEES OF A CAPITAL ACCESS COMPANY*
OFFICIAL USE ONLY
LAST NAME
Date submitted CII:
Applicant
I.D.#
PLEASE PRINT OR TYPE
NAME OF COMPANY: __________________________________________
FILE NO. _______________
ADDRESS OF MAIN OFFICE: ___________________________________________________________________
(Street)
(City)
(State)
(Zip Code)
EMPLOYING BRANCH OFFICE: ________________________________________________________________
NAME OF OFFICER, DIRECTOR, PARTNER, “CONTROL” PERSON, MANAGER, MEMBER, TRUSTEE
AND EMPLOYEE:
________________________________________________________________________________________________________________________________________________________
(Last)
(First)
(Middle)
POSITION HELD OR TO BE HELD: _____________________________________________________________
HOME ADDRESS: ____________________________________________________________________________
(Street)
(City)
(State)
(Zip Code)
DATE OF BIRTH: __________________________ PLACE OF BIRTH: ______________________________
(Month)
(Day)
(Year)
HEIGHT: ______________ WEIGHT: ____________ SEX: __________
COLOR OF EYES: ____________
COLOR OF HAIR: ____________
*
This document shall be treated by the Department of Corporations as being received in confidence pursuant to
paragraph (4) of subdivision (d) of Section 6254 of the Government Code.
CACL 280.153

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