ࡱ> FHCDE @ Zbjbj5*5* RW@W@gSrNNNbbb8bt2d'fl(lllqowtKwl$ӡR%XNB}o^qoB}B}ll[B}RlNlB}f|,"Nސlf @prRb}XV 0'}"~P}$ސb$}NސxxyzE{xxx6B=D%rB= STATE OF SOUTH CAROLINA DEPARTMENT OF CONSUMER AFFAIRS ORIGINATOR LICENSE APPLICATION SUPPLEMENTAL FORM O S.C. Code Ann. 40-58-10 et seq. (Supp. 2004)  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) This form may be duplicated. Print legibly or type information requested on 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 and License Number: FORMTEXT      (your current employer)South Carolina address where employed:  FORMTEXT      (Street Address, City, State and Zip)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.)Present 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      REASON FOR SUBMISSION(Check appropriate box and give complete information for each section checked) FORMCHECKBOX Initial Application FORMCHECKBOX Renewal Application FORMCHECKBOX Name Change (Give your new legal name): FORMTEXT      Last Name, First Name and Middle Name (NOT Initial) FORMCHECKBOX Home Address Change (Former Home Address): FORMTEXT      Street Address FORMTEXT      City, State, Zip and Telephone Number FORMCHECKBOX Employment Changes (Former Employer) FORMTEXT      Company Name and License Number:Address where employed: FORMTEXT      Street Address, City, State and Zip  FORMCHECKBOX Business Address Change FORMTEXT      (Former Address Where Employed)Street Address FORMTEXT      City, State, Zip and Telephone NumberEMPLOYMENT BACKGROUND Describe your employment, at least five 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 been convicted of a felony or of an offense involving breach of trust, moral turpitude or dishonest dealings within the past ten years? (Include all offenses other than minor traffic violations.) 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? 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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).  FORMCHECKBOX  FORMCHECKBOX Has 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 Are you licensed in any other jurisdiction in any capacity in the mortgage industry, if yes, provide details? 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.______________________________________________ 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 O Rev. 01/08 Page  PAGE 1 of  NUMPAGES 2 Street Address 3600 Forest Drive Columbia, SC 29204-4406 Mailing Address P.O. 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