Fs 512 Siq Form – Fill Out and Use This PDF

FS 512 Siq Form is an essential document in the world of permits and applications. It provides businesses and organizations with the most efficient, convenient, and secure way to submit their documents to official government agencies. The form ensures accuracy as far as data entry goes, as well as ensures that the relevant authority already has the information needed for processing. In fact, considering its high standards, a FS 512 Siq Form can help institutions save time and reduce paperwork associated with permit registration. Furthermore, it also serves as a dependable asset when following up on any programs that require permission from local or outside leadership to be implemented successfully. Its usefulness simplifies how leaders manage compliance checks while also generating enough flexibility within operational protocols. FS 512 Siq Form is truly an instrument created to save precious hours of physical and mental energy concerning tedious paperwork related issues.

Fs 512 Siq Form PDF Details

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Question	Answer
Form Name	Fs 512 Siq Form
Form Length	6 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 30 sec
Other names	statement of identity form, statement identity pdf, department identity 512 form, california department identity template

Form Preview Example

STATE OF CALIFORNIA – DEPARTMENT OF BUSINESS OVERSIGHT

STATEMENT OF IDENTITY AND QUESTIONNAIRE

DBO – FS 512 SIQ (REV. 11-13)

File Number, if any

Licensee (Company Name)

Insert Department of Business Oversight file number, if any, and the name of the licensee (company) to which this Statement of Identity and Questionnaire relates.

Legal Full Name

First Name	Middle Name	Last Name
	(Do not use initials or nicknames)

Position to be filled in connection with the preparation of this questionnaire (e.g., Officer, Director, Manager, etc.).

Sex

Hair

Eyes

Height

Weight

Birthdate

Birthplace

Social Security Number

California Driver's License Number

See Commissioner’s Release 2-G regarding

(if none, so state)

whether furnishing the social security number is

mandatory or voluntary and for a description of the

use made of that information.

Residence

Business

Phone Number

Hours of Employment

Address

(e.g., 8:00 a.m. to 5:00 p.m.)

FS 512 SIQ (Rev. 11/13)

Insert Full Name	Insert Licensee
of Individual: _______________________	(Company Name):

1.Residence addresses for the last 10 years:

From	To	Street	City	State	Zip Code

	Present

Attach separate schedule if space is not adequate.

2.Employment for the last 10 years:

From	To	Employer Name and Address	Occupation and Duties

	Present

Attach separate schedule if space is not adequate.

FS 512 SIQ (Rev. 11/13)

Insert Full Name	Insert Licensee
of Individual: _______________________	(Company Name):

3.a. Have you ever been named in any order, judgment or decree of any court or any governmental agency or administrator, temporarily or permanently restraining or enjoining you from engaging in or continuing any conduct, practice or employment?

Yes

If the answer is "Yes", give details:

Attach a copy of any order, judgment or decree.

b.Are you currently, or have you been within the last ten years, under federal, state or local investigation for possible violation of any law, ordinance, or licensing or regulatory scheme?

Yes

If the answer is "Yes", give details:

4.a. Are you currently licensed to engage in financial business in this state or any other state?

Yes

Financial business means securities broker-dealer or agent, investment adviser or investment adviser representative, financial planner, insurance agent, escrow agent, finance lender or broker, mortgage lender or servicer, real estate broker, payday lender, financial institution, bill payer or prorater, commodity sales person, certified public accountant, or any other business involving investment or financial transactions.

If the answer is "Yes", describe in the chart below the following for each license:

License Period	License	Type of License/Business	Name and Address of Licensing Entity
	Number
	Number

From:
To:

From:
To:

Attach separate schedule if space is not adequate.

b.Have you ever been refused a license to engage in any business in this state or any other state, or has any such license ever been suspended, revoked, or surrendered subject to a settlement, or any other similar action?

Yes

If the answer is "Yes", give details:

FS 512 SIQ (Rev. 11/13)

Insert Full Name	Insert Licensee
of Individual: _______________________	(Company Name):

Attach a copy of any settlement.

5.Have you ever been convicted of or pleaded nolo contendere to a misdemeanor or felony other than minor traffic citations that do not constitute a misdemeanor or felony offense?

"Convicted" includes a verdict of guilty by judge or jury, a plea of guilty or of nolo contendere or a forfeiture of bail. All convictions must be disclosed even if the plea or verdict was thereafter set aside and the charges against you dismissed or expunged or if you have been pardoned. Convictions occurring while you were a minor must be disclosed unless the record of conviction has been sealed under Section 1203.45 of the California Penal Code or Section 781 of the California Welfare and Institution Code.

Yes

If the answer is "Yes", give details:

Attach a copy of any order, judgment or decree. If a conviction was entered under Section 23152(a) of the Vehicle Code, attach a written declaration stating whether drugs were involved.

6.Have you ever been a defendant in a civil court action other than divorce, condemnation or personal injury?

Yes

If the answer is "Yes", please complete the following:

Date of suitLocation of court

Nature of suit

Attach a copy of any order, judgment or decree.

7.Have you ever been a subject of a bankruptcy or a petition in bankruptcy?

Yes

If the answer is "Yes", give date, title of case, location of bankruptcy filing:

8.Have you ever been refused a bond, or have you ever had a bond revoked or canceled?

Yes

If the answer is "Yes", give details:

FS 512 SIQ (Rev. 11/13)

Insert Full Name		Insert Licensee
of Individual: _______________________		(Company Name):

9.Have you ever changed your name including a woman’s maiden name, or ever been known by any name other than that herein listed?

Yes

If so, explain. Change in name through marriage or court order and exact date of each name change must be listed.

Prior Name	Date of Name Change
__________________________________________	___________________________________
__________________________________________	___________________________________

10.Have you ever done business under a fictitious firm name either as an individual or in any form of business, e.g., partnership, limited liability company, corporation or other?

Yes

If the answer is "Yes", give details:

The following questions must be answered by all persons submitting this questionnaire in connection with an

ESCROW AGENT’S LICENSE.

11.In what capacity will you be employed?

(e.g., Clerk, Escrow Officer, Manager, Officer, Director, etc.)

12.Do you expect to be a party to, or broker or salesman in connection with escrows conducted by the escrow company which is employing you?

Yes

If the answer is "Yes", give details:

This statement will be considered confidential information and will be filed and maintained as part of the confidential records not subject to public inspection.

FS 512 SIQ (Rev. 11/13)

VERIFICATION

I, the undersigned, state that I am the person named in the foregoing Statement of Identity and Questionnaire; that I have read and signed said Statement of Identity and Questionnaire and know the contents thereof, including all exhibits attached thereto, and that the statements made therein, including any exhibits attached thereto, are true, and that I have not omitted any information needed to make this document true.

This verification may be made either before a Notary Public or as a declaration under penalty of perjury. This form MUST be executed before a Notary Public if it is executed OUTSIDE the State of California.

I certify/declare under penalty of perjury that the foregoing is true and correct.

Executed at

(City)

State of		)

County of		)
Date		, 20
at

	(Signature of Individual)
Subscribed and sworn to before me

___________________ ______, 20______

__________________________________

Notary Public in and for said County and State

	(County)	(State)
this	day of	, 20________.

(Print Name)

(Signature of Individual)

FS 512 SIQ (Rev. 11/13)

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This document needs some specific details; in order to ensure consistency, make sure you take heed of the next recommendations:

1. For starters, once filling in the california siq, beging with the form section containing following fields:

Filling in section 1 of state california siq sample

2. Right after the previous part is done, go to type in the relevant details in all these - Position to be filled in, California Drivers License Number, Hours of Employment eg am to pm, and Business Phone Number.

Part no. 2 in filling in state california siq sample

3. Completing Insert Full Name of Individual, Residence addresses for the last, Insert Licensee Company Name, From, Street, City State Zip Code, and Present is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Step no. 3 in completing state california siq sample

4. Now fill in this fourth segment! In this case you've got all these From, Employer Name and Address, Occupation and Duties, Present, Attach separate schedule if space, and FS SIQ Rev form blanks to complete.

Step number 4 of filling out state california siq sample

5. This form has to be finalized by dealing with this segment. Here you will see an extensive set of fields that need accurate details to allow your document usage to be faultless: Insert Full Name of Individual, Insert Licensee Company Name, a Have you ever been named in any, Yes, Yes, and a Are you currently licensed to.

state california siq sample writing process explained (part 5)

Always be very careful when filling in Insert Licensee Company Name and a Have you ever been named in any, because this is where most users make some mistakes.

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Fs 512 Siq Form – Fill Out and Use This PDF

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