Eligibility Determination Application Form-Confirmation Authorization (Page 3 of 3) in pdf

Eligibility Determination Application Form-Confirmation Authorization Page 3

PART III – SIGNATURE

VERIFICATION / CONFIRMATION AUTHORIZATION

I AUTHORIZE THE TEXAS DEPARTMENT OF SAVINGS AND MORTGAGE LENDING, OR ITS DESIGNEE OR ASSIGNS,

TO OBTAIN ANY AND ALL INFORMATION THEY DEEM NECESSARY REGARDING MY LEGAL STATUS/HISTORY

AND PERSONAL AND/OR PROFESSIONAL BACKGROUND, INCLUDING A CRIMINAL BACKGROUND CHECK, IN

ORDER TO DETERMINE ELIGIBILITY AND DISPOSITION OF MY APPLICATION.

ANY AND ALL RELEASE OF

INFORMATION REQUESTED BY THE TEXAS DEPARTMENT OF SAVINGS AND MORTGAGE LENDING FROM

SOURCES OF INFORMATION IS WITH MY FULL AND UNCONDITIONAL AUTORIZATION.

I AUTHORIZE THE TEXAS DEPARTMENT OF SAVINGS AND MORTGAGE LENDING TO REPRODUCE THIS

ACKNOWLEDGED FORM AS MANY TIMES AS NECESSARY TO OBTAIN THE NECESSARY INFORMATION;

THEREFORE, A COPY BEARING MY SIGNATURE SHOULD BE CONSIDERED THE SAME AUTHORIZATION AS THE

ORIGINAL.

I HOLD EACH COMPANY AND AGENCY PROVIDING REQUESTED INFORMATION TO THE TEXAS DEPARTMENT OF

SAVINGS AND MORTGAGE LENDING AND ITS OFFICERS, DIRECTORS, AGENTS AND/OR EMPLOYEES HARMLESS

FOR ACCURATELY AND PROMPTLY FURNISHING THE REQUESTED INFORMATION.

CERTIFICATION

UNDER PENALTY OF PERJURY, I HEREBY SWEAR OR AFFIRM THAT ALL THE FOREGOING INFORMATION AND ALL

THE INFORMATION PROVIDED WITH THIS APPLICATION IS TRUE AND CORRECT TO THE BEST OF MY

KNOWLEDGE AND I UNDERSTAND THAT ANY FALSE REPRESENTATION, MISREPRESENTATION OR MATERIAL

OMISSION IN THIS APPLICATION, NO MATTER WHEN DISCOVERED, MAY SERVE AS A BASIS FOR FUTURE DENIAL

OF MY LICENSE, REVOCATION OF MY LICENSE, ADMINISTRATIVE PENALTIES AND/OR OTHER DISCIPLINARY

ACTIONS OR REMEDIES ALLOWED BY LAW.

I UNDERSTAND THAT FAILURE TO ANSWER ANY QUESTION TRUTHFULLY ON THIS APPLICATION MAY RESULT

IN AN INACCURATE ELIGIBILTY DETERMINATION.

SIGNATURE: __________________________________

Applicant

DATE: __________________________________

Page 2 of 2

Revised 9/1/2013

Eligibility Determination Application Form-Confirmation Authorization Page 3