Free Officers' Interrogatory Form - Nebraska

OFFICERS' INTERROGATORY
This interrogatory must be completed by each officer or other individual having a right to participate in the management of the applicant's business in the State of Nebraska. If additional forms are needed, copies may be made. _____________________________________________________________
Name of Officer

___________________________________
Title

______________________________________________________________________________________________________
Residence Address, City, State, Zip

List the places where you have been engaged in any kind of business or vocation accounting for the entire period since you left school or college. If additional space is needed, attach a separate sheet to application. Nature of Business ______________________________________________________________________________________ Employer ______________________________________________________________________________________________ Address ________________________________________________________________________________________________ Position held ____________________________________________________ From ____________ To ____________

Nature of Business ______________________________________________________________________________________ Employer ______________________________________________________________________________________________ Address ________________________________________________________________________________________________ Position held ____________________________________________________ From ____________ To ____________

Nature of Business ______________________________________________________________________________________ Employer ______________________________________________________________________________________________ Address ________________________________________________________________________________________________ Position held ____________________________________________________ From ____________ To ____________

Nature of Business ______________________________________________________________________________________ Employer ______________________________________________________________________________________________ Address ________________________________________________________________________________________________ Position held _____________________________________________________ From ____________ To ____________

Nature of Business ______________________________________________________________________________________ Employer ______________________________________________________________________________________________ Address ________________________________________________________________________________________________ Position held _____________________________________________________ page 1 From ____________ To ____________

page 2 Have you ever been engaged in any kind of collection agency work? _____ yes _____ no If so, how long? _____________

Describe position ________________________________________________________________________________________ Have you ever been licensed in any other state as an owner, manager, or solicitor of a collection agency? _____ yes _____ no If so, where? __________________________________________________________ When? __________________________ Has your application for a license as an owner, manager, or solicitor of a collection agency ever been rejected in any other state? _____ yes _____ no If so, explain giving exact dates, places, parties involved, and full details on a separate sheet. Has your license as an owner, manager, or solicitor of a collection agency ever been revoked or suspended in any other state? _____ yes _____ no If so, explain giving exact dates, places, parties involved, and full details on a separate sheet. Have you ever been convicted of any criminal offense or is there any criminal charge against you now pending (other than minor traffic violations)? _____ yes _____ no If so, explain giving exact dates, places, parties involved, and full details on a separate
sheet.

Have you been convicted of fraud in any court within the past five years? _____ yes _____ no
dates, places, parties involved, and full details on a separate sheet.

If so, explain giving exact

Has there been any judgment entered against you for failure to account to your client money or property for such client or customer in the last five years? _____ yes _____ no If so, explain giving exact dates, places, parties involved, and full details
on a separate sheet.

Have you read and do you understand the provisions of the Collection Agency Licensing Act? _____ yes _____ no List the names and addresses of three people unrelated to you who can attest to your reputation for honesty and fair dealings. Name __________________________________________________________________________________________________ Address _________________________________________________________________________________________________ Name __________________________________________________________________________________________________ Address _________________________________________________________________________________________________ Name __________________________________________________________________________________________________ Address _________________________________________________________________________________________________ AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize the Secretary of State as Chairman of the Nebraska Collection Agency Board to investigate and verify any information contained in my collection agency application or any other information relevant to my qualifications for licensure. ____________________________________________________ Signature ___________________________________ Social Security Number * (optional)

*Failure to disclose your social security number will not affect your license application, but will be used by the Board to assist in verifying background information provided, including credit history checks. The number is being requested under Nebr. Revised Statute 45-607 which lists qualifications and disqualification's for licensees and officers, and in accordance with previous Collection Agency Licensing Board practice.