ࡱ> @ bjbjFF ",,*SrVKKK8VKDL VhNT(TTTW\w_poqqqqqq$RfXCe9W^WCeCeTT["jjjCevRTTojCeojjy|"7{TN 0U3EKeF;zc| 80hMze$7{$>7{,`ajb5c```VV,2Dj4VV2 STATE OF SOUTH CAROLINA DEPARTMENT OF CONSUMER AFFAIRS OWNER/EMPLOYEE INFORMATION SUPPLEMENTAL FORM A S.C. Code Ann. 40-58-10 et seq. (Supp. 2003)  HYPERLINK "http://www.scconsumer.gov/" www.scconsumer.gov 803-734-4236/800-922-1594 DO NOT FAX THIS FORM (An original, signed and notarized form is required) The following information MUST be provided on a separate form for EACH MEMBER, OWNER, PARTNER, CORPORATE OFFICER, SHAREHOLDER AND EMPLOYEE, other than originators. The term employee on this form means any person employed by the business other than those who engage in direct loan brokerage activity, including processors. Employees that engage in direct loan brokerage activity, i.e. originators must be separately licensed and do not require a Supplemental Form A. This form may be duplicated. Complete the form in its entirety. If any of the information on this form changes, submit a revised form to the Department. Incomplete information could result in delay or denial of your application. Company name:  FORMTEXT      Your legal name:  FORMTEXT      Last Name, First Name and Middle Name (NOT Initial)Business relationship or title:  FORMTEXT      *If an owner, partner, officer or member, state your ownership interest (Ex. 25%)  FORMTEXT      Have you been known by any other name?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, state the name  FORMTEXT       (Ex. Maiden name, etc.)Do you work in the broker business?  FORMCHECKBOX Yes  FORMCHECKBOX NoPresent Home/Street Address:  FORMTEXT      How long at this address?  FORMTEXT   City:  FORMTEXT      State:  FORMTEXT   Zip: FORMTEXT      County:  FORMTEXT      Work telephone:  FORMTEXT    - FORMTEXT    - FORMTEXT     Home telephone:  FORMTEXT    - FORMTEXT    - FORMTEXT     Date of Birth:  FORMTEXT      SSN:  FORMTEXT    -  FORMTEXT   -  FORMTEXT     Fax:  FORMTEXT    - FORMTEXT    - FORMTEXT     (mm/dd/yyyy)E-Mail:  FORMTEXT      In what state were you born?  FORMTEXT   Driver s License No.  FORMTEXT      State & Date of Issue:  FORMTEXT      EDUCATIONAL BACKGROUND SCHOOL DATES ATTENDED DEGREE (also indicate major)  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        EMPLOYMENT BACKGROUND Describe your employment, at least ten years, starting with current, noting origination of residential mortgages. NAME OF EMPLOYER ADDRESS & TELEPHONE NO. DATES OF EMPLOYMENT POSITION NAME OF OWNER  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       Mark an X in the appropriate box. If you answer "Yes" to any question, give all details on a separate sheet. YESNO FORMCHECKBOX  FORMCHECKBOX Have you ever been convicted of a felony or of an offense involving breach of trust, moral turpitude or dishonest dealings within the past ten years? Provide details about the offense, including conviction date, court, penalty and attach a certified copy of the Criminal Docket Sheet and the Presentence Investigation Report.  FORMCHECKBOX  FORMCHECKBOX Have you ever been charged with irregularities or shortages in your business accounts or transactions? If yes, provide details. FORMCHECKBOX  FORMCHECKBOX Have you ever surrendered, resigned, cancelled or been denied a professional license or other credential in any jurisdiction? Provide details including the name of the profession and the agency (include agency address).  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< = K L M N O ] ^ _ ǵoWEo-/jBhGhD1sCJOJQJU^JaJ#hGhe'5CJOJQJ^JaJ/jCBhGhD1sCJOJQJU^JaJ hGhMCJOJQJ^JaJ)jhGhMCJOJQJU^JaJ#he'B*CJOJQJ^JaJphhe'CJOJQJ^JaJ#he'he'5CJOJQJ^JaJhnCJOJQJ^JaJ he'hnCJOJQJ^JaJhe')hhe'B*CJOJQJ^JaJphz- . / 0 \({{u{e\({$$If`a$gd*J$$If`a$gd[RRkdj@$$Ifl0h*4) t44 la($ & p@ P !d$7$8$H$Ifa$gde'0 1 2 6 9 : {{{D{p#{$$If`a$gd[R$$If`a$gd[RRkd@$$Ifl0h*4) t44 la: ; < N ` !{w{gzgDzWp#{$$If`a$gd[R$$If`a$gde'$$If`a$gd[RxkdA$$Ifl\h8T*H$ t44 la_ ` !!!!!!!!!!!!!!!D"S"T"V"Y"["\"]"k"μμ~fXμμhCJOJQJ^JaJ/jEhGhD1sCJOJQJU^JaJ/jDhGhD1sCJOJQJU^JaJ hGhMCJOJQJ^JaJ)jhGhMCJOJQJU^JaJ#he'he'5CJOJQJ^JaJhe'CJOJQJ^JaJ he'he'CJOJQJ^JaJ#hGhe'5CJOJQJ^JaJ!!!!!!w{g{gD{Wp#{$$If`a$gd[R$$If`a$gde'$$If`a$gd[Rxkd+C$$Ifl\h8T*H$ t44 la!!!!!U"{w{gzgDzWp#{$$If`a$gd[R$$If`a$gde'$$If`a$gd[RxkdC$$Ifl\h8T*H$ t44 laU"V"W"X"Y"Z"w{g{gD{Wp#{$$If`a$gd[R$$If`a$gde'$$If`a$gd[RxkdE$$Ifl\h8T*H$ t44 laZ"["\"n""_#{w{gzgDzWp#{$$If`a$gd[R$$If`a$gde'$$If`a$gd[RxkdDF$$Ifl\h8T*H$ t44 lak"l"m"n"o"}"~"""^#`#c#e#f#g#u#v#w#x#y##үxfxfүNү/j_IhGhD1sCJOJQJU^JaJ#he'he'5CJOJQJ^JaJhe'CJOJQJ^JaJ he'he'CJOJQJ^JaJ/jsGhGhD1sCJOJQJU^JaJ hGhMCJOJQJ^JaJ#hGhe'5CJOJQJ^JaJ)jhGhMCJOJQJU^JaJ/jFhGhD1sCJOJQJU^JaJ_#`#a#b#c#d#qw{g{gD{Wp#{$$If`a$gd[R$$If`a$gde'$$If`a$gd[RxkdG$$Ifl\h8T*H$ t44 lad#e#f#x## {w{gzgDzSp#{$d$7$8$H$Ifa$gde'$$If`a$gde'$$If`a$gd[RxkdH$$Ifl\h8T*H$ t44 la#### "(,.0LNPRTprtvqYqA/j7LhGhD1sCJOJQJU^JaJ/jKhGhD1sCJOJQJU^JaJ hGhMCJOJQJ^JaJ#he'he'5CJOJQJ^JaJhe'CJOJQJ^JaJ he'he')he'he'B*CJOJQJ^JaJphU#hGhe'5CJOJQJ^JaJ)jhGhMCJOJQJU^JaJ/jIhGhD1sCJOJQJU^JaJHas any licensing or other credentialing agency ever taken any disciplinary action against you, including but not limited to, any warning, reprimand, suspension, probation, limitation or revocation? Provide details, including the name of the agency and date of action.  FORMCHECKBOX  FORMCHECKBOX Is disciplinary action pending against you in any jurisdiction? Provide details, including the name of the agency and status of action.  FORMCHECKBOX  FORMCHECKBOX Have you ever had any civil judgments, lawsuits or liens brought against you? If yes, provide details.  FORMCHECKBOX  FORMCHECKBOX Do you currently hold, or have you in the past, held any credential (license) issued by the State of South Carolina? If yes, what type of credential? (Do not include drivers license)  FORMTEXT       FORMCHECKBOX  FORMCHECKBOX Have you read and are you familiar with the Mortgage Loan Broker Act, S.C. Code Ann. 40-58-10 et seq.? (Must answer YES if you work in the broker business) Describe any training you have received in mortgage brokering, including on-the job-training (OJT). FORMTEXT      I swear or affirm and certify that I have completed and/or reviewed all information on this form and that all information contained herein is true, current and correct. I further certify that I understand that giving false information constitutes cause for denial or revocation of the application and subjects me to criminal prosecution for perjury. I acknowledge that I have a duty and agree to update and correct this information as it changes. Additionally, I acknowledge that pursuant to SC Code 40-58-10 through -110 a criminal records check by the South Carolina Law Enforcement Division will be obtained for all applicants.______________________________________________ FORMTEXT      Signature of Owner/EmployeeType or Print your name and Business Relationship or TitleSWORN TO AND SUBSCRIBED before me this _________ day of _________________________, 20__ _________________________________________________ Notary Public For ___________________________________ My Commission Expires: _____________________________The South Carolina Freedom of Information Act may require the Department of Consumer Affairs to release this form as a public record; however personal identifying information will be released only if required by law. Mortgage Broker Supplemental Form A Rev. 04/05 Page  PAGE 1 of  NUMPAGES 2 Street Address 3600 Forest Drive Columbia, SC 29204-4406 Mailing Address P.O. 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