Nebraska Collection Agency Board Initial Collection Agency License Application - Nebraska Secretary Of State
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1
2JOHN A. GALE
State Capitol
Secretary of State
Room 1305
Lincoln, NE 68508
NEBRASKA COLLECTION AGENCY BOARD
INITIAL COLLECTION AGENCY LICENSE APPLICATION
Please complete the following questions. If additional space is needed for any question, you may attach a separate sheet to the application.
The investigation fee of $200.00 and the license fee of $200.00 must be paid when the application is submitted. The investigation fee is non-
refundable.
Date ____________________________
Applicant is a(n): Individual ____ Partnership ____ LLC ____ Corporation ____
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Agency Name ______________________________________________________________________________________
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Agency Owner(s)____________________________________________________________________________________
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(List all owners holding shares or ownership interests in the agency along with the percentage of interest held)
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Business Street Address ___________________________________________________________________________________
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Telephone No. _____________________________________
Fax No. _____________________________________
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Licensing Contact Person _________________________________Telephone No. _______________ Email Address____________________
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Complaint Contact Person _________________________________Telephone No._______________ Email Address____________________
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Nebraska Office Street Address _____________________________________________________________________________
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(Out of state agencies must have a Nebraska Office Address – Refer to Chapter 10 of the Rules and Regulations)
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Telephone No. __________________________________ Contact Person _____________________________________
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1. Discuss in brief your business history, organizational structure, type of collection related business engaged in (or to be engaged in, if not yet
active) and if you have been in business prior to this application or have ever held a Nebraska Collection Agency License.
2. �Does your business handle accounts and money?
____ yes ____ no
3. �If licensed, have you ever had any disciplinary action by an agency or board? ____ yes ____ no If yes, explain on a separate sheet.
4. Will the business use any additional names for the collection agency? ____ yes ____ no If yes, list on a separate sheet. (Including
registered trade names).
5. �Applicants who are corporations or limited liability companies: please list on a separate sheet the names and resident addresses of the
president, vice president, secretary, treasurer and other officers having a right to participate in the management of the collection agency.
6. �Applicants licensed in another state: attach a listing of the states and the agencies issuing the license.
7. Out of state applicants already doing business outside Nebraska: please list ten (10) customers showing their names, complete
addresses, and telephone numbers for reference purposes on the attached sheet.
8. Individual or Partnership applicants must provide three (3) letters of personal reference (each).
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