Free Initial Collection Agency License Application Form - Nebraska

JOHN A. GALE
Secretary of State

State Capitol Room 1305 Lincoln, NE 68508

NEBRASKA COLLECTION AGENCY BOARD INITIAL COLLECTION AGENCY LICENSE APPLICATION
Please complete the following questions. If additional space is needed for any question, you may attach a separate sheet to the application. The investigation fee of $200.00 and the license fee of $200.00 must be paid when the application is submitted. The investigation fee is nonrefundable. Date ____________________________ Applicant is a: Individual ____ Partnership ___ LLC ___ Corporation ___

Agency Name ______________________________________________________________________________________ Agency Owner(s)____________________________________________________________________________________ Business Address ___________________________________________________________________________________ Telephone No. _____________________________________ Contact Person _________________________________ Fax No. _____________________________________

Telephone No. ___________________________________

Nebraska Office Address _____________________________________________________________________________
(Out of state agencies must have a Nebraska Office Address ­ Refer to Chapter 10 of the Rules and Regulations)

Telephone No. __________________________________ Contact Person _____________________________________ 1. Discuss in brief your business history (when your company started, where they have done business, etc.) and if you have been in business prior to this application.

2. Are you, or is your business, registered with the Better Business Bureau or Chamber of Commerce in your city? If so, list the name of city and state ________________________________________________________ 3. Does your business handle accounts and money? ___ yes ___ no

___ yes ___ no

4. If licensed, have you ever had any disciplinary action by an agency or board? ____ yes ____ no If so, explain on a separate sheet. 5. Will the business use any additional names for the collection agency? ____ yes ____ no If applicable, list on a separate sheet. (Including registered trade names). 6. Applicants who are corporations or limited liability companies: please list on a separate sheet the names and resident addresses of the president, vice president, secretary, treasurer and other officers having a right to participate in the management of the collection agency. 7. Applicants licensed in another state: attach a listing of the states and the agencies issuing the license. 8. Out of state applicants already doing business outside Nebraska: please list ten (10) customers showing their names, complete addresses, and telephone numbers for reference purposes on the attached sheet. 9. Individual or Partnership applicants must provide three (3) letters of personal reference (each).

Oath of Applicant

STATE OF ____________________ COUNTY OF __________________
Print Name

) ) ss. )
Capacity of affiant, i.e. president, owner, general manager

I, ______________________________, do hereby swear or affirm as __________________________________ of ________________________________________, That I have personally verified the information contained in the attached
Name of Collection Agency

Initial Collection Agency Application and Nebraska Collection Agency Board Personal/Corporate Financial Statement and the information contained therein is true and correct to the best of my knowledge. _________________________________ Signature SUBSCRIBED AND SWORN to before me this _____ day of ____________, 20____. ________________________________ Notary Public