Ofr-Com-101 - Registration Of Commercial Collection Agency
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2MAIL TO:
OFFICE OF FINANCIAL REGULATION
200 East Gaines Street
Tallahassee, FL 32399-0376
Check payable to Department of Financial Services – Fee: $500.00
REGISTRATION OF COMMERCIAL COLLECTION AGENCY
This form shall be accompanied by certified payment of a $500.00 non-refundable registration fee. All requirements for registration
must be satisfied within forty-five (45) days from the date of request for additional information.
TYPE OR PRINT
1(a). Legal Name of Commercial Collection Agency: __________________________________________________________
1(b). If corporate name is not allowed in Florida, provide name approved by the Florida Secretary of State:
_______________________________________________________________________________________________
(Provide qualification document from the Florida Secretary of State. This is the name that will appear on your license and
should appear on your surety bond. See instructions.)
DBA Name (If applicable): __________________________________________________________________________
(Provide acknowledgment from the Dept. of State, Division of Corporations that your fictitious name is duly registered.)
2.
Federal Employer l.D. Number: __ __ - __ __ __ __ __ __ __(If Social Security Number, response to Question 2 should be
entered on Exhibit A of this application)
(F.E.I.D. number is required of all corporations. See IRS "Instructions for Form SS-4.")
3.
Principal Place of Business (Note: Post Office Box is not acceptable.)
_______________________________________________________________________________________________
Street Address
_______________________________________________________________________________________________
City
County
State
Zip
4.
Mailing Address if different from above:
_______________________________________________________________________________________________
P.O. Box or Street Address
_______________________________________________________________________________________________
City
County
State
Zip
Telephone Number: (___) _________________________
Fax/Email: _______________________________
5.
Type of Agency: (Check One) ____ Domestic Corporation
____ Foreign Corporation
(Documentation of registration from the Florida Secretary of State Office to conduct business in the State of Florida is required of
Foreign Corporations.)
6.
Date of Incorporation _______________ State of Incorporation __________________
(Documentation of Incorporation must be filed with this application.)
7.
Provide a list of the current business location of each branch office in the State of Florida of the registering agency. If none,
indicate such.
8.
Provide a list of the following information on Exhibit A of this application:
a)
If a partnership or sole proprietorship, provide full name, residence address, telephone number, and social security
number of all owners.
b)
If a corporation, provide full name, residence address, telephone number, and social security number (federal identification
number if a corporate owner), of all Corporate Officers, Directors, Owners, and Florida Resident Agent.
**************************************************************FOR OFFICE USE ONLY*****************************************************
APPROVED BY: _________________ DATE APPROVED: $500:
OFR-COM-101 Rev. 05-01-04
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