Commissioner of Financial Regulation
Business Registration Form
01-15
To ensure that your registration form is complete, please review each question and use the check box
when all items or questions are
satisfied. Failure to file a completed registration form may result in the rejection of your registration. Your responses to the questions on
this form are continuing in nature. Please note that You refers to any person included as part of this registration form, including any
business entity. This form can be mailed to: Office of the Commissioner of Financial Regulation, 500 N. Calvert Street, Suite 402,
Baltimore, MD 21202. Please type or print clearly in dark ink.
ALL REGISTRANTS MUST COMPLETE THIS SECTION
1. Check the business category for which you are registering.
Exempt Collection Agency Registrants Maryland Code Annotated, Business Regulation 7-102(b) (10)
Consumer Reporting Agencies - COMAR Title 9 Subtitle 3 Chapter 7.03
2. Registrant is:
Corporation
Partnership
Unincorporated Association
Limited Liability Partnership
Limited Liability Company
Individual/Sole Proprietorship
3. Registrants tax ID or social security #: ___________________________________________________________________
4. Legal name of registrant: ______________________________________________________________________________
5. Trade name or DBA name under which registrant will conduct business:
___________________________________________________________________________________________________
6. Name, address, telephone number, fax number and email address of registrants resident agent:
Name
Address
City
Direct
Telephone #
Fax
State
Toll Free
Number
Email
Zip code
State
Toll Free
Number
Email
Zip code
7. Business address of registrants principal office:
Address
City
Direct
Telephone #
Fax
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SECTION A: CONSUMER REPORTING AGENCY REGISTRANTS ONLY
A1. Registrant is completing:
Original registration
Renewal registration
A2. Any changes in Registrants previously provided disclosures since submission of last registration form?
Yes Update applicable sections and complete Section D.
No If you have checked no, please proceed to and complete Section D.
A3. Registrant must provide a toll free number to be used by the Commissioner, or the Commissioners designee:
A4. Registrant must provide a toll free number(s) to be used by residents of this State for inquiries:
A5. Provide mailing address which any consumer of this State may use to correspond with registrant for the purpose of obtaining
copies of consumer reports, filing written complaints, or disputing credit information:
Name
Address
City
State
Zip code
A6. Name, address, telephone number, fax number and email address of registrants principal contact for compliance matters:
Name
Address
City
Direct
Telephone #
Fax
State
Toll Free
Number
Email
Zip code
A7. Name, address, telephone number and email address of registrants principal contact for consumer complaints:
Name
Address
City
Direct
Telephone #
Fax
State
Toll Free
Number
Email
Zip code
SECTION B: EXEMPT COLLECTION AGENCY REGISTRANTS ONLY
B1. Does registrant collect debts for other person(s)?
Yes
No
B2. Is the registrant and the person(s) for whom the registrant is collecting a debt related by common ownership (Note: common
ownership means direct or indirect ownership of more than 50% of a person)?
Yes
No
B3. Does the registrant only collect debts for those persons to whom it is related by common ownership?
Yes
No
B4. Is the principal business of the registrant the collection of debts (Note: principle business means a business activity of a person
that comprises more than 50% of the total business activities of the person.)
Yes
No
B5. Name of entity under common ownership that registrant would be collecting debts for and percentage of ownership:
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NAME OF ENTITY
PARENT COMPANY
PERCENTAGE OF OWNERSHIP
B6. Please proceed to and complete Section C.
.
SECTION C: ALL REGISTRANTS MUST COMPLETE THIS SECTION
THE UNDERSIGNED HEREBY CERTIFIES AND AGREES TO THE FOLLOWING:
1.
2.
3.
4.
The information submitted in this registration and any attachments hereto is correct, complete, and accurate;
Registrant will promptly submit any information which may be required for consideration of this registration form;
Registrant will provide trained personnel sufficient to promptly and properly investigate and respond to Maryland consumer
complaints and inquiries; and
Registrant will promptly notify the Commissioner of Financial Regulation of any changes in the information contained in this
registration form.
AFFIDAVIT
I, _______________________________________________, STATE UNDER PENALTY OF PERJURY THAT THE FOREGOING
(NAME OF INDIVIDUAL)
INFORMATION IN THIS REGISTRATION FORM, INCLUDING INFORMATION PROVIDED IN EACH REQUIRED
ATTACHMENT HERETO, IS TRUE, CORRECT AND COMPLETE.
STATE OF ______________________________
______________________________________________
(SIGNATURE OF INDIVIDUAL)
CITY / COUNTY _________________________
______________________________________________
(TITLE)
Personally appeared before me, _________________________________________________,
(NAME OF INDIVIDUAL)
who being duly sworn according to law, deposes and says that the statements contained in this
registration form are true and correct.
Sworn and subscribed before me this _____ day of _____________________, 20 ____.
_____________________________________________
(NOTARY PUBLIC)
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