The application for such license shall be in writing, under oath and in the form prescribed by the Secretary of Banking. The application shall contain the corporate title of the applicant and any registered or otherwise qualified name to be used as a fictitious business name; the street and number, if any, city, borough, township or municipality, and county where the business is to be conducted; date of incorporation; name and residence address of all directors; and such other information as the Secretary of Banking may require.

A separate application on the prescribed form shall be filed for each place of business conducted by a licensee.