Texas Department Of Licensing And Regulation Personal Information Form printable pdf download

PO Box 12157  Austin, Texas 78711-2157

(800) 803-9202  (512) 463-6599  FAX (512) 463-5984

 cs.service.contract.providers@tdlr.texas.gov

SERVICE CONTRACT PROVIDER CONTROLLING PERSON - PERSONAL INFORMATION FORM

This form must be completed by each controlling person as defined in Occupations Code, Section 1304.0035

NOTE: All information must be typed or printed in ink.

1. Name of Registered or proposed service contract provider under which this personal information is required:

________________________________________________________________________________________________

2. Controlling Person’s Full Name:

_______________________________________

_________________________

__________________

____

Last

First

Middle

Suffix

3. Other Name(s) (if applicable):

4. Date of Birth:

____________ - _________ - ____________

__________________________________________________

Month

Day

Year

6. *Social Security Number:

5. Gender:

Male

Female

(See below for disclosure information)

______ ______ ______

_____ _____

______ ______ ______ ______

7. Title: ______________________________________________ 8. Percentage of Ownership: ___________%

9. Phone Number:

10. **Email Address:

(______) ______________________

Area Code

Phone Number

Email address (ex: ) (See below for disclosure information)

11. Home Address:

(a PO Box cannot be used for this address)

Number, Street Name, Suite Number

City

State

Zip Code

12. ANSWER THE FOLLOWING QUESTIONS:

(if you have any doubt about the accuracy of an answer, the question should be answered “Yes” and an explanation provided.)

Has any business for which you are or were a controlling person filed a petition under any chapter of the U.S. Bankruptcy Code or

Yes

been placed in receivership?

Yes

Are you operating or acting as a controlling person for any other service contract provider, administrator or seller?

Have you or a service provider, administrator or seller in which you are or were a controlling person ever been denied or refused

Yes

a license or license renewal in any state?

Have you or a service provider, administrator or seller in which you are or were a controlling person ever been disciplined by a

Yes

state regulatory body?

Yes

Have you or a service contract provider, administrator or seller in which you are or were a controlling person ever been subject to

a cease and desist letter or order, or enjoined, either temporarily or permanently, in any judicial, administrative, regulatory or disci-

plinary action?

Yes

Have you or a service contract provider, administrator or seller in which you are or were a controlling person ever had a license

issued under Title 13 of the Texas Insurance Code revoked?

Yes

Have you or a service contract provider, administrator or seller in which you are or were a controlling person ever had a provider,

administrator, or seller license or registration revoked in any state?

Yes

Have you or a service contract provider, administrator or seller in which you are or were a controlling person ever been convicted

of, or placed on deferred adjudication for, any misdemeanor or felony, other than a minor traffic violation?

If you answered “Yes” to any of the above questions, attach copies of documentation and separate pages providing the

necessary details including names, contact information, dates, locations, and dispositions.

13. Signature:

I certify that I will comply with all applicable provisions of Texas Occupations Code, Chapter 51, and 1304, and 16 Texas Adminis-

trative Code, Chapter 60 and 77. I certify all information submitted on this form and any attachments is true and accurate. I understand that providing

false information on this application or any attachment may result in imposition of administrative penalties and/or sanctions, including revocation of the

registration.

Applicant Signature

Date Signed

Title

Printed Name

Social security number (SSN) disclosure is required by Section 231.302(1) of the Texas Family Code in

Please provide your email address so the department may email license information

order to obtain a license. Your SSN is subject to disclosure to an agency authorized to assist in the collec-

and required notices to you. Your email address is confidential pursuant to the Texas

tion of child support payments. For more information regarding child support payments, contact the Texas

Public Information Act, and the department will not share it with the public.

Attorney General at: or call (512) 460-6000 or (800) 252-8014.

TDLR FORM SCP009 rev April 2015

Texas Department Of Licensing And Regulation Personal Information Form

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