Bca Form - Residential Mortgage Originator Or Servicer License Application
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1STATE OF MINNESOTA
RESIDENTIAL MORTGAGE ORIGINATOR or
DEPARTMENT OF COMMERCE
SERVICER LICENSE APPLICATION
Division of Financial Examinations
85 7th Place East, Suite 500
MINNESOTA BUREAU OF CRIMINAL
St. Paul, Minnesota 55101
APPREHENSION (BCA) FORM
(651) 539-1723
The data, which you furnish on this form, will be used by the Department of Commerce to assess your qualifications for a
license. Individuals listed on the Disclosure of Company Owners, Partners, Officers form must complete this BCA
form. Disclosure of your social security number is voluntary; however, if not provided, the Department of Commerce may
be unable to grant a license. The Department of Commerce requires this information and may conduct criminal history
checks and/or verify tax identification information and for revenue recapture as authorized by Minnesota Statutes, Chapter
270A. After issuance of a license, all information contained in this application, except your social security number, is
public pursuant to Minnesota Statutes, Chapter 13.
TO:
Bureau of Criminal Apprehension and Minnesota Department of Revenue
RE:
Request for Criminal Background Check
Request for Disclosure/Verification of Tax Identification Number
***PLEASE PRINT***
License applied for:
Residential Mortgage Originator OR
Residential Mortgage Servicer
Name of applicant (or person in control)
Title or position in the company
Social Security Number of applicant (or person in control) Applicant’s (or person in control’s) date of birth
The following section should only be completed if you are applying for a company (rather than individual)
license:
Name of the company:
Company’s Federal EIN: ___ ___ -- ___ ___ ___ ___ ___ ___ ___
The following section to be completed by all applicants:
I,
(Full First Name)
(Full Middle Name)
(Full Last Name)
have made application to the Minnesota Department of Commerce for a regulated professional license. I am either
the applicant or the limited/general partner, a manager, a shareholder of the applicant owning 10% or more of the
stock, or an employee with the authority to exercise management/policy control over the company. I hereby
request/authorize the Bureau of Criminal Apprehension to conduct a background check of me through their records
for licensing purposes, and the Minnesota Department of Revenue to disclose/verify the company’s tax I.D.
number.
Signature of Applicant
Date
NOTE TO BUREAU OF CRIMINAL APPREHENSION / MN DEPARTMENT OF REVENUE:
Please enclose completed background investigation or tax identification information in a sealed envelope along
with this letter.
BCA FORM
MN/DOC 5/2007
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