State Form 49718/form Lb 4 - Application For Registration As A Principal Manager Or An Originator Page 3
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10B. SECTION INSTRUCTIONS CONTINUED
SECTION 4 – LOAN BROKER VERIFICATION – This section must be completed and signed by an authorized party of the
licensed loan broker.
1. ESTABLISH RELATIONSHIP – Applicants must apply to establish an employment relationship with a licensed loan
broker by submitting a new registration application (State Form 49718/LB 4).
2. TRANSFER REGISTRATION – A registered principal manager or originator may transfer their registration to another
licensed loan broker by filing an amendment. Check the “Amend Existing Registration” box, complete Sections 1(A), 1(I)
through 1(M), 4, and 9. The new employer must complete Section 4(A) and the previous employer must complete Section
4(B). The original certificate of registration being withdrawn must be returned to the Secretary of State, Securities
Division within five (5) days of the termination as required by Indiana Code § 23-2-5-10(h).
3. TERMINATE RELATIONSHIP – For the purposes of this form, “terminate” refers to the ending of the employment
relationship between the registrant and the licensed loan broker. Pursuant to Indiana Code § 23-2-5-10(h)(2) applicants or
the employer (licensee) must submit the State Form 49718/Form LB 4 to notify the Secretary of State, Securities Division
that the employment relationship has ceased. Sections 1(A), 4(B), 9, must be completed and returned with the original
certificate of registration and reason for termination to the Secretary of State, Securities Division within five (5) days of
the termination as required by Indiana Code 23-2-5-10(h). Section 4(B) must be completed and signed by an authorized
party of the loan broker.
SECTION 5 – RESIDENTIAL HISTORY
Starting with current address (Section 1(L)), give all addresses for the past ten (10) years, leaving no gaps. (Attach additional
sheets as necessary.) Post Office boxes are not acceptable. Report changes as they occur.
YOU MUST ACCOUNT FOR ALL
TIME LEAVING NO
GAPS.
SECTION 6 – EMPLOYMENT HISTORY
Provide complete employment history for the past ten (10) years, leaving no gaps. All entries must include the beginning and end
dates of employment. Provide the full legal name of the company, beginning with your current employer. Account for all time
including full & part-time employment, self-employment, military service, and homemaking. Also include periods such as
unemployment, full-time student, extended travel, etc. For the purposes of this history, include both 1099 independent contractor
assignments as well as W-2 status employment. Indicate by “YES” or “NO” whether this employment was financial service-related
business. (Attach additional sheets as needed.)
YOU MUST ACCOUNT FOR ALL TIME LEAVING NO GAPS.
An applicant for registration as a principal manager must provide evidence that the applicant has at least three (3) years of
experience, acceptable to the Commissioner as a loan broker or in financial services. Individuals applying for registration as a
principal manager must include a detailed description of the relevant employment, including a description of the duties performed
and the name and contact information of the person you reported to.
SECTION 8 - DISCLOSURES
Questions must be answered fully, and must include all actions or legal proceedings occurring in any court in any jurisdiction. If
the answer to any of the questions is “YES”, provide complete details of all events or proceedings in an attachment, listing the
offense, cause number, date of conviction, and the court in which the individual was convicted.
Additionally for bankruptcies,
submit a copy of the discharge paperwork or a statement identifying the current status of the bankruptcy.
Refer to the explanation
of terms section of the instructions for explanations of italicized terms.
SECTION 9 – INDIVIDUAL VERIFICATION
By signing the verification, the principal manager/originator is affirming that the application is true and complete, that he/she has
not been convicted of a felony within the previous five (5) years or a crime of fraud or deceit within the previous ten (10) years. If
the applicant has been convicted of a felony within the previous five (5) years or a crime of fraud or deceit in the previous ten (10)
years, this information must be disclosed by attaching additional pages listing the offense, cause number, date of conviction, and
the court in which the individual was convicted. The Commissioner may deny registration based on this information.
State Form 49718 (R5 / 6-08) / Form LB 4
Page 3 of 10
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