Instructions/application/personal Certification-State Of New Jersey Form Page 2
ADVERTISEMENT
1
2
3
4Return to:
Licensing Services,
Banking
STATE OF NEW JERSEY
N.J. Dept. of Banking and
Insurance
DEPARTMENT OF BANKING and INSURANCE
PO Box 473
Trenton, NJ 08625
LICENSING SERVICES BUREAU, BANKING
HIGH-COST HOME L0AN CREDIT COUNSELING AGENCY
REGISTRATION
TYPE OR PRINT CLEARLY
1.
Name of Applicant:_______________________________________________________________________
D/B/A or Alternate Name (if applicable)_________________________________________________________
1.
New Jersey principal office address: ________________________________________________________
(include city, state, county, zip code & phone #)
________________________________________________________________________________________
3. Address of each additional location where counseling will occur:
(include city, state, county, zip code & phone #)__________________________________________________
________________________________________________________________________________________
_________________________________________________________________________________________
(A listing of other locations can be an attachment if all information requested above is provided).
4.
Name of Branch Manager/Person in Charge of this location_______________________________________
5.
Federal Employer ID # (FEIN) ________________________________
6. E-mail Address_____________________________________________
7. Has any officer, director, trustee or member of an advisory or other similar committee ever had a license, permit or
other authorization (other than a driver’s license) suspended or revoked by this or any other state or been affiliated,
directly or indirectly, with any organization that has had such a license suspended or revoked? Yes _____ No____
(Attach a complete written explanation if “yes.”).
_______________________________________
_____________________________________________
Print Name of Corporate President
Signature of Corporate President
__________________________________________________
Date
___________________________________________
___________________________________________________
Print Name of Corporate Secretary
Signature of Corporate Secretary
________________________________________________________________
Date
Subscribed and sworn to before me at
__________________________________________________
this ______________day of_____________________20_____
__________________________________________________
(Official Title)
HCHLCCA3/08
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Nj-w4 - Employee's Withholding Allowance Certificate - State Of New Jersey Division Of Taxation
Financial
Form Nj-w4 - Employee's Withholding Allowance Certificate - State Of New Jersey - Division Of Taxation
Financial
Related Categories
Parent category: Business