Michigan > Secretary Of State > Blue Sky > Securities > Debt Management
Debt Management Act Business History Form FIS-0512 - Michigan
| Debt Management Act Business History Form Form. This is a Michigan form and can be used in Debt Management Securities Blue Sky Secretary Of State . |
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FIS 0512 (4/11) Office of Financial and Insurance Regulation Page 1 of 3 Debt Management Act Business History Form PLEASE NOTE: This form, along with three Affidavits of Character forms and a Fingerprint Card (available through OFIS by calling 1-877-999-6442) MUST be completed for each officer, director, partner, proprietor, member counselor, and office manager. (Note: This form is not required to be completed by a director or its equivalent, if he/she does not receive a salary, stock dividend, or other financial benefit from the corporation or equivalent entity, other than reimbursement of the actual expenses incurred in carrying out the duties of a director of that corporation or equivalent entity.) Make copies as needed. Name Address Debt Management Firm Employment Date / / Date Employed as Counselor (if applicable) / / Part Time Full Time Position with this Firm Date of Birth U.S. Citizen / YES NO YES NO / YES NO Educational Institutions attended. Institution Address Dates Attended Year Completed or Degree List your employment for the last five years starting with current position. Account for all time (if unemployed, disclose and provide dates). Name of Employer and Complete Address From To Position Held Reason for leaving List all home addresses for the past five years starting with present address. Number and Street City State From To American LegalNet, Inc. www.FormsWorkFlow.com FIS 0512 (4/11) Office of Financial and Insurance Regulation Page 2 of 3 Debt Management Act Business History Form Answer each question. If you answer "yes" to any of the following, please attach complete details. YES NO Have you been adjudicated as bankrupt or were you ever a partner, director, officer, member or manager of any firm or company which was adjudicated as bankrupt or for which a receiver was appointed wither during the time or within one year after you were connected with it? Have you been the subject of receivership proceedings? Have you made an assignment for the benefit of creditors? Have you been convicted of a misdemeanor or a felony (excluding motor vehicle traffic misdemeanors)? Have you been refused any license by the Office of Financial and Insurance Regulation or any other governmental body? Have you had any license suspended or revoked? Have you had application for license withdrawn? Have you been charged in any suit with any fraudulent or dishonest acts in any transaction? Have you been involved in any civil litigation arising out of the debt management business? Have you defaulted in the payment of money collected for others? Is there any litigation pending against either yourself or any firm or company of which you are now a partner, officer, director, member or manager? YES YES YES NO NO NO YES NO YES YES YES NO NO NO YES NO YES YES NO NO American LegalNet, Inc. www.FormsWorkFlow.com FIS 0512 (4/11) Office of Financial and Insurance Regulation Page 3 of 3 Debt Management Act Business History Form Describe the experience you have had in the business of debt management: ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ I do hereby certify that the above information is true and correct: Signature Date 1975 PA 148 as amended required submission of this form by applicants for a license to do business as a Debt Management company. Failure to complete and submit this form properly could result in denial, suspension or revocation of your license. American LegalNet, Inc. www.FormsWorkFlow.com
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