Fill and Sign the Financial Assistance Policy Prohealth Care Prohealthcare Form

STATE OF ALASKA DEPARTMENT OF COMMERCE, COMMUNITY AND ECONOMIC DEVELOPMENT DIVISION OF BANKING AND SECURITIES P.O. BOX 110807, JUNEAU, ALASKA 99811-0807 TELEPHONE (907) 465-2521 http://www.commerce.state.ak.us/bsc/banking.htm APPLICATION FOR A SMALL LOAN COMPANY LICENSE Application is hereby made for a license to conduct the business of a Small Loan Company under the provisions of the Alaska Small Loans Act, AS 06.20 and the regulations adopted under it. A. GENERAL INFORMATION Name of Applicant (Complete name under which business is to be conducted) Business Address (State of Alaska) (If home office is outside of State of Alaska, give address) Type of Business Organization: Corporation Partnership Limited Liability Company If incorporated, state and date of incorporation (Attach a certified copy of your current Articles of Incorporation, Certificate of Authority and/or Certificate of Incorporation.) Names of all officers and directors of the corporation, members of a partnership or other business entity: NAME TITLE RESIDENCE OTHER OCCUPATION 1. The applicant is engaged in the Small Loan business in the following states: 2. Is any officer, director, or employee of your organization interested in or connected with any other license under this act? Yes No State facts: 3. Has any member of your organization previously held a license under this or any previous similar or related act? Yes No State facts: Page 1 of 2 4. Enclose a Resolution of the Board of Directors authorizing application for license. 5. Name of Surety Company bonding officers and employees: 6. (a) Does any director or officer of the corporation have a license to engage in the business of an insurance agent or broker? Yes No (b) Has any license of any director or officer of the corporation, in this state or any state been denied, suspended or revoked? Yes No If so, give details: 7. Has the applicant or any director or officer been convicted of any criminal offense other than a traffic violation within the last ten years? Yes No (If yes, furnish complete details on separate sheet.) 8. Has the applicant or any director or officer had a final judgment issued against him/her in a civil action on Yes No account of fraud, misrepresentation or deceit within the last ten years? (If yes, furnish complete details on separate sheet.) 9. Has the applicant or any director or officer filed bankruptcy within the last ten years? Yes No 10. Are your financial records audited by an independent auditing firm? Yes If yes, state name and address of firm and attach a copy of the most recent audit report: No ______________________________________________________________________________________ B. FINANCIAL STATEMENT Attach a statement of the financial condition of the applicant. An authorized officer attesting to the truth and correctness of the statement must sign the statement. Specify the date of the financial condition. C. OFFICE MANAGER Submit the name, home address, and resume of the proposed office manager. The resume must document employment history during the last 10 years. D. REGISTERED AGENT Applicant hereby appoints the Commissioner of the Department of Community and Economic Development and/or Director, Division of Banking, Securities, and Corporations, as agent to accept service of process. I/We hereby certify, upon personal knowledge, that the foregoing information is true and correct. Name Title Name Title Name Title Name Title Subscribed and sworn to before me this SEAL day of Notary Public My Commission Expires: Page 2 of 2 , 20