Exhibit C - Statement Of Identity And Questionnaire
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4STATE OF CALIFORNIA
DEPARTMENT OF CORPORATIONS
EXHIBIT C
File No., if applicable
Licensee (Company Name)
(Insert Department of Corporations file number, if any, and the name of the licensee (company) to which this Statement of Identity and
Questionnaire relates.)
This document (together with any fingerprint cards) 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.
STATEMENT OF IDENTITY AND QUESTIONNAIRE
Exact Full Name
(Please Print)
First Name
Middle Name
Last Name
(Do not use initials or nicknames)
Position to be filled in connection with the preparation of this questionnaire (e.g. Officer, Director, Manager, etc.).
Sex
Hair
Eyes
Height
Weight
Birthdate
Birthplace
Social Security or
California Driver's License
Taxpayer's Identification No.
No. if applicable
NOTE: See Commissioner's Release 2-G, attached, regarding whether or not furnishing the social security number is mandatory or
voluntary and for a description of the use made of that information.
Residence
Business
Hours of
Phone No.
Phone No.
Employment
1.
Residence addresses for the last 10 years:
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NOTE: Attach separate schedule if space is not adequate
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EXHIBIT C
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