State Form 49718/form Lb 4 - Application For Registration As A Principal Manager Or An Originator Page 9
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10Applicant full legal name (last, first, middle): _____________________________________________________
Regulatory Action Disclosure
YES
NO
(H) Has any State or federal regulatory agency or foreign financial regulatory authority ever:
(1) found you to have made a false statement or omission or been dishonest, unfair or unethical?
(2) found you to have been involved in a violation of a financial services-related regulation(s) or
statute(s)?
(3) found you to have been a cause of a financial services-related business having its authorization to do
business denied, suspended, revoked or restricted?
(4) entered an order against you in connection with a financial services-related activity?
(5) denied, suspended, or revoked your registration or license, disciplined you, or otherwise by order,
prevented you from associating with a financial services-related business or restricted your activities?
6) barred you from association with an entity regulated by such commission, authority, agency, or officer,
or from engaging in a financial services-related business?
(7) issued a final order based on violations of any law or regulations that prohibit fraudulent,
manipulative, or deceptive conduct?
(I) Are you now the subject of any regulatory proceeding that could result in a "yes" answer to any part of
8(H)?
Civil Judicial Disclosure
YES
NO
(J) (1) Has any domestic or foreign court ever:
(a) enjoined you in connection with any financial services-related activity?
(b) found that you were involved in a violation of any financial services-related statute(s) or
regulation(s)?
(c) dismissed, pursuant to a settlement agreement, a financial services-related civil action
brought
against you by a State, federal, or foreign financial regulatory authority?
(2) Are you named in any pending financial services-related civil action that could result in a "yes" answer to any
part of 8(J)(1)?
Customer Arbitration/Civil Litigation Disclosure
YES
NO
(K) Have you ever been named as a respondent/defendant in a financial services-related consumer-initiated
arbitration or civil litigation which:
(1) is still pending; or
(2) resulted in an arbitration award or civil judgment against you, regardless of amount, or that required
corrective action; or
(3) was settled for any amount?
9. INDIVIDUAL VERIFICATION:
I solemnly swear or affirm under the penalties of perjury that:
A. I have completed the academic instruction listed in Section 2, all courses are listed on the Division’s approved course list or I have
attached evidence that the Commissioner has approved the course(s);
B. I have not been convicted in any jurisdiction of a felony within the previous five (5) years or a crime involving fraud or deceit in the
previous ten (10) years other then which is disclosed herein or on the attached documents; and
C. the information appearing in this application form and the attached documents hereto is true, accurate, and complete to the best of my
knowledge.
Signature
Title
Date (MM/DD/YYYY)
State Form 49718 (R5 / 6-08) / Form LB 4
Page 9 of 10
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