Texas Form Pc132 – Fill Out and Use

		TDI USE ONLY	FPCARD: ﾅ
Texas Department of Insurance		CO. ID:	LIC.#:
Property & Casualty Program - Title Division, Mail Code 106-2T		PID:	EXP:
333 Guadalupe ｺ P. O. Box 149104, Austin, Texas 78714-9104		ISSUE:	RIDER:	ﾅ
512-322-3482 telephone ｺ 512-305-7426 fax ｺ www.tdi.texas.gov
		R.R.#:	OTHER:	ﾅ

ＤＳＳＯＬＦＤＷＬＲＱ＃ＩＲＵ＃ＷＨ［ＤＶ＃ＨＶＦＵＲＺ＃ＲＩＩＬＦＨＵﾶＶ＃ＯＬＦＨＱＶＨ＃

***ACTING AS AN ESCROW OFFICER BEFORE YOUR LICENSE IS ISSUED IS A VIOLATION OF §2652.001 AND IS SUBJECT TO DISCIPLINARY ACTION INCLUDING FINES AND LICENSE DENIAL AND/OR REVOCATION (see Title Bulletin No. 164)***

INSTRUCTIONS

1.Applicant (and employer attorney if applicable) must complete Section A.

2.Sponsoring title agent/direct operation must complete Section B.

3.Licensing fee of $35.00 must be submitted.

4.Texas escrow officer's schedule bond must be attached, if needed. (If bond is already on file, rider or endorsement must be attached).

5.Fingerprints and criminal history information ﾱ＃see addendum regarding requirements

SECTION A -- ESCROW OFFICER IDENTIFICATION

Mr.

1.

Name in full: Mrs. Last

First

Middle

Ms.

(No initials accepted)

(No initials accepted)

2.

Residence Address

City

State

Zip

Phone No. (

)

3.

E-Mail Address

(required for notification purposes)

－Ｌｉ＃｜ｒｘ＃ｄｑｖｚｈｕ＃ﾳ＼ｈｖﾴ＃ｗｒ＃ｔｘｈｖｗｌｒｑ＃＜ｄ／＃＜ｅ／＃＜ｆ／＃ｄｑｇ２ｒｕ＃＜ｇ／＃｜ｒｘ＃ｐｘｖｗ＃ｖｘｅｐｌｗ＃ｒｕｌｊｌｑｄｏ＃ CERTIFIED copies of the indictment or charging document, conviction, order deferring adjudication, judgment and conditions of probation from the appropriate jurisdiction, for each and every crime or offense. You may also include letters of recommendation on your behalf. Please provide full information with dates and details on a separate sheet of paper. Application processing will be suspended until the details are received and a review is completed. If certified documents have been previously submitted to

PC132 Rev. 08/11

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NOＷＨ＝＃＃ＬＩ＃＼ＲＸ＃ＤＱＶＺＨＵ＃ﾳ＼ＨＶﾴ＃ＷＲ＃ＤＱ＼＃ＲＩ＃ＴＸＨＶＷＬＲＱＶ＃４３＃ＷＫＵＲＸＪＫ＃４：／＃＼ＲＸ＃ＰＸＶＷ＃ＤＷＷＤＦＫ＃Ｄ＃ＳＨＵＶＲＱＤＯ＃

STATEMENT WITH DATES AND COMPLETE DETAILS. APPLICATION PROCESSING WILL BE SUSPENDED UNTIL THE DETAILS ARE RECEIVED AND A REVIEW IS COMPLETED.

10.	Have you ever had a professional license, an insurance license or company appointment
	refused, suspended or revoked in Texas or any other state?		ﾅ YES	ﾅ NO
11.	Are you now indebted to a special deputy receiver of the Texas Department of Insurance,
	any insurance company, general agent or agent?		ﾅ YES	ﾅ NO
12.	Have you ever had an agency contract canceled for cause (e.g., misrepresentation,
	misappropriation, etc.)?		ﾅ YES	ﾅ NO
13.	Have you ever been placed under injunction or restraining order of a court or regulatory
	agency in respect to violation of any federal or state law relating to insurance or securities?		ﾅ YES	ﾅ NO
14.	Do you now have pending litigation against you alleging violation of the Texas Insurance Code
	or the insurance laws of any other state?		ﾅ YES	ﾅ NO
15.	Have you ever held ownership interest in any insurance agency or company?		ﾅ YES	ﾅ NO
16.	Do you have any judgments against you held by any insurance company or insured which
	are unpaid in whole or in part?		ﾅ YES	ﾅ NO
17.	Do you have any judgments against you which involved violation of the Texas Insurance Code
	or the insurance laws of any other state?		ﾅ YES	ﾅ NO
18.	Do you have another business name or alias?		ﾅ YES	ﾅ NO
	If YES, indicate business name or alias here:
19.	Have you ever held a professional license, insurance license or company appointment under
	any other name?		ﾅ YES	ﾅ NO

If YES, indicate other name(s) here:

If YES, and you indicate you are a bona fide employee of a title insurance agent/direct operation in question No. 21, you certify by signing this application that the existing license will be canceled within 60 days or you are a bona fide employee of separate title insurance agents/direct operations. If you are a bona fide employee of separate title insurance agents/direct operations, you may be required to provide supporting documentation (see Title Bulletin No. 162).

21.Check applicable status of employment for this application:

ﾅI am a bona fide employee of the title agent/direct operation

ﾅI am an attorney

ﾅI am a bona fide employee of an attorney who is a Texas licensed escrow officer

EMPLOYER ATTORNEY MUST COMPLETE THE FOLLOWING ONLY IF APPLICANT CHECKED THE THIRD BOX ABOVE.

Printed name of attorney licensed as escrow officer

Signature of attorney (by signing attorney confirms escrow oｉｉｌｆｈｕ＃ｄｓｓｏｌｆｄｑｗﾶｖ＃ｖｗｄｗｘｖ＃ｒｉ＃ｈｐｓｏｒ｜ｐｈｑｗ，＃

Sworn to and subscribed before me on ______________________________ to certify which witness my hand and seal of

office.

(Notary Seal)

Nｒｗｄｕ｜＃Ｓｘｅｏｌｆﾶｖ＃Ｖｌｊｑｄｗｘｕｈ＃

Reminder: Securing the issuance of this license based upon a false, fictitious, or fraudulent statement or entry with regard to any material fact is subject to both disciplinary action and criminal prosecution.

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22.County(ies) in which you intend to act as an escrow officer

(MUST BE A COUNTY(IES) IN WHICH THE TITLE AGENT/DIRECT OPERATION SHOWN ON SECTION B IS LICENSED TO OPERATE)

23.Give complete details of all (including current) employment, self-employment, or unemployment during the last five

(5) years.

Dates		Employer Name		Employer Address (Street, City, State, Zip)		Title/Position

24.Give the name, street address and phone number of three (3) business or professional references from the community where you have resided for the last five years.

Name		Address (Street, City, State, Zip)		Phone		Type of Business

Reminder: Securing the issuance of this license based upon a false, fictitious, or fraudulent statement or entry with regard to any material fact is subject to both disciplinary action and criminal prosecution.

Print/Type Full Legal Name

CERTIFICATION

THE STATE OF _______________________

COUNTY OF __________________________

Before me, the undersigned authority, on this day personally appeared

known to me to be the affiant, who, after being placed on his/her oath, stated that he/she has read the preceding form and that the answers, exhibits and attachments forming it are true and correct as to any factual statements contained therein.

Signature of Affiant

Sworn to and subscribed before me on ______________________________ to certify which witness my hand and seal of

office.

(Notary Seal)

Notary Pｘｅｏｌｆﾶｖ＃Ｖｌｊｑｄｗｘｕｈ＃

NOTICE ABOUT CERTAIN INFORMATION LAWS AND PRACTICES

With few exceptions, you are entitled to be informed about the information the Texas Department of Insurance (TDI) collects about you. Under sections 552.021 and 552.023 of the Texas Government Code, you have a right to review or receive copies of information about yourself, including private information. However, TDI may withhold information for reasons other than to protect your right to privacy. Under section 559.004 of the Texas Government Code, you are entitled to request that TDI correct information that TDI has about you that is incorrect. For more information about the procedure and costs for obtaining information from TDI or about the procedure for correcting information kept by TDI, please contact the Agency Counsel Section of TDI's Legal Services Program at AgencyCounsel@tdi.state.texas.us or you may refer to the Corrections Procedure section on our Web sites.

PC132 Rev. 08/11

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SECTION B -- TITLE AGENT IDENTIFICATION AND CERTIFICATION

Notice of Appointment of Escrow Officer by Title Insurance Agent/Direct Operation

Reminder: Securing the issuance of this license based upon a false, fictitious, or fraudulent statement or entry with regard to any material fact is subject to both disciplinary action and criminal prosecution.

This notice of appointment ofis for a license

to act as an escrow officer for the Title Insurance Agent/Direct Operation identified below. If and when the appointment is terminated or canceled, the Texas Department of Insurance will be properly notified.

The applicant is known to this Agent/Direct Operation to have a good business reputation, is worthy of the public trust, has reasonable experience or instruction in the field of title insurance and is qualified as an escrow officer as defined in the "Texas Title Insurance Act". I know of no fact or condition which would disqualify such applicant from receiving a license.

Appointing Title Insurance Agent/Direct Ｒｓｈｕｄｗｌｒｑ＃ｆｒｑｉｌｕｐｖ＃ｄｓｓｏｌｆｄｑｗﾶｖ＃ｖｗｄｗｘｖ＃ｒｉ＃ｈｐｓｏｒ｜ｐｈｑｗ＃ｌｑｇｌｆｄｗｈｇ＃ｌｑ＃Ｖｈｆｗｌｒｑ＃Ｄ＃Ｑｒ１＃５４＃ of this application.

Ｄｓｓｒｌｑｗｌｑｊ＃Ｗｌｗｏｈ＃Ｌｑｖｘｕｄｑｆｈ＃Ｄｊｈｑｗ２Ｇｌｕｈｆｗ＃Ｒｓｈｕｄｗｌｒｑ＃ｆｒｑｉｌｕｐｖ＃ｄｓｓｏｌｆｄｑｗﾶｖ＃ｆｒｘｑｗ｜＋ｌｈｖ，＃ｒｉ＃ｒｓｈｕｄｗｌｒｑ＃ｄｖ＃ｌｑｇｌｆｄｗｈｇ＃ｌｑ＃Ｖｈｆｗｌｒｑ＃Ｄ＃ No. 22 of this application.

Appointing Title Insurance Agent/Direct Operation confirms it will not allow the applicant to act as an escrow officer until the Title Insurance Escrow Officer License has been issued by the Texas Department of Insurance.

Appointing Title Insurance Agent's/Dｌｕｈｆｗ＃Ｒｓｈｕｄｗｌｒｑﾶｖ＃Ｗｈ｛ｄｖ＃Ｇｈｓｄｕｗｐｈｑｗ＃ｒｉ＃Ｌｑｖｘｕｄｑｆｈ＃Ｆｒｐｓｄｑ｜＃＆＃

Name of Title Agent/Direct Operation Contact Person					Ｆｒｑｗｄｆｗ＃Ｓｈｕｖｒｑﾶｖ＃ｈ-mail address (required for notification purposes)
Name of Appointing Title Agent/Direct Operation			Mailing Address (P. O. Box/Street)					City, State, Zip
Full Name of Title Agent/Direct Operation Appointing Official					Title of Appointing Official

CERTIFICATION

THE STATE OF _______________________

COUNTY OF __________________________

Before me, the undersigned authority, on this day personally appeared

known to me to be the affiant, who, after being placed on his/her oath, stated that he/she has read the preceding form and that the answers, exhibits and attachments forming it are true and correct as to any factual statements contained therein.

Signature of Affiant

Sworn to and subscribed before me on ______________________________ to certify which witness my hand and seal of

office.

(Notary Seal)

Notary Ｓｘｅｏｌｆﾶｖ＃Ｖｌｊｑｄｗｘｕｈ＃

	Regular Mailing Address	Overnight Mailing Address
	Texas Department of Insurance	Texas Department of Insurance
	Title Division, Mail Code 106-2T	Title Division, Mail Code 106-2T
	P.O. Box 149104	333 Guadalupe Street
Refer Questions To: (512) 322-3482	Austin, Texas 78714-9104	Austin, Texas 78701

PC132 Rev. 08/11

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