Set forth the name, address, principal place of business, telephone and fax numbers of the applicant. If applicable, also state any trade or fictitious names which have been or will be used by the applicant.

State whether the applicant is an individual, corporation, partnership or trust. If an individual, set forth the name, residence address and telephone and fax numbers of the individual applicant. If a corporation, set forth the name, residence address, telephone and fax numbers and percent of each class of outstanding capital stock owned by each executive officer, director and principal stockholder. If a partnership, set forth the name, residence address, telephone and fax numbers and percentage ownership of each controlling member of the partnership. If a trust, set forth the name, residence address and telephone and fax numbers of each trustee and principal beneficiary of the trust. If a corporation, list the number and percentage of stock owned by each stockholder owning less than 10 percent of any class of the outstanding capital stock. If a partnership, state where the articles of partnership were filed and the date of filing. If a corporation, indicate the state of incorporation and the date of filing. List the complete name and address of any branch, subsidiary, or other affiliate of the applicant operating in this State.

Set forth the name, complete address and telephone and fax numbers of the person(s) having general responsibility for the applicant to whom all communications from the department should be addressed and the person(s) responsible for regulatory and financial matters.

List all states in which the applicant, under this or any other name, or any subsidiary or other affiliate of the applicant, is licensed to engage in any of the following: banking, insurance, sales finance, small loan, mortgage lending, insurance premium financing, real estate or securities, together with the name of the operating company and the name and address of the agency responsible for supervising the person or entity. Also, list any other professional licenses held by any of the foregoing.

The applicant, under this or any other name, any subsidiary or other affiliate of the applicant, and, as applicable, any officer, director and principal stockholder of a corporate applicant, any controlling member of a partnership applicant and any trustee and principal beneficiary of a trust applicant shall submit information with respect to any refusal, revocation or suspension of license(s) in this or any other state and/or any prior bankruptcy adjudications or criminal convictions in this or any other state.

The applicant, under this or any other name, any subsidiary or other affiliate of the applicant, and, as applicable, any officer, director and principal stockholder of a corporate applicant, any controlling member of a partnership applicant and any trustee and principal beneficiary of a trust applicant shall submit information with respect to any finding of having conducted unsafe or unsound practices while employed as an officer, director, or trustee of a banking organization or having been removed as an officer, director, or trustee of a banking organization by any bank regulatory agency.

As applicable, each individual applicant, each director, the three most senior executive officers and, if different, any officer(s) in charge of the New York operations of the registered mortgage broker and principal stockholder of a corporate applicant, each controlling member of a partnership applicant, or trustee and principal beneficiary of a trust applicant shall file a credit report and a personal history questionnaire which may be obtained from the department. Each principal stockholder shall complete a personal financial questionnaire. All of the above shall file an authority to release information form.

List all of applicant's W-2 employees (name and social security number), excluding clerical staff unless involved in the actual mortgage brokerage business, with their titles and a statement of occupational activities. List all persons (name and social security number) for whom an undertaking of accountability will be filed.

Set forth the name of the person who meets the minimum experience qualifications as described in Part 410 of this Title. That person shall be either an owner, general partner, trustee or executive officer of the applicant, as applicable, and shall be actively engaged in the daily operations of the mortgage broker. Indicate the category that best describes the type of experience:

(j) Corporate, partnership or trade style documents to be submitted, as applicable:

(k) Other documents to be submitted: