Free APPLICATION FOR APPROVAL OF LOAN BROKER ACADEMIC INSRUCTION COURSE - Indiana

APPLICATION FOR APPROVAL OF LOAN BROKER ACADEMIC INSTRUCTION COURSE
State Form 53272 (R2 / 4-08) Approved by State Board of Accounts, 2007

PLEASE READ CAREFULLY:
YOU MUST SUBMIT THE FOLLOWING:
· · · · · · Non-refundable initial application fee of $400 and $25 per credit hour above six (6) credit hours Non-refundable renewal application fee of $400 and $25 per credit hour above six (6) credit hours For a live course: application, script or detailed presentation notes, timeline of course (how much instruction time will be spent on each topic), course book, and any materials to be distributed For a video course: application, script of video, copy of video, timeline of course (how much instruction time will be spent on each topic), course book, and any materials to be distributed For a correspondence course: application, time line of course (how much time would the average student spend on each topic), course book, and any materials to be distributed For an on-line course: application, script of presentation if streaming audio, print-out of each screen, timeline of course (how much instruction time will be spent on each topic), and any supplemental materials

This application and submission is for the approval of the named course ONLY. Each course must be submitted individually. You may request a certain number of credit hours. However, determination of credit hour approval will be based on time of actual instruction with length of lecture and length of materials considered. Twenty-four (24) hour courses must consist of live instruction and contain at least one (1) hour of instruction on Indiana loan broker law and at least two (2) hours of instruction on federal loan broker law. Approval of each course is for ONE YEAR. To renew a course approval, you must submit a properly completed application, the renewal application fee, and all course material, with all changes from the previously approved version clearly marked. A PERSON WHO KNOWINGLY FILES WITH THE COMMISSIONER ANY DOCUMENT OR STATEMENT THAT CONTAINS A FALSE REPRESENTATION OF A MATERIAL FACT IS SUBJECT TO THE IMPOSITION OF A CIVIL PENALTY OF UP TO $10,000 PER VIOLATION; AND CHARGED WITH A CLASS C FELONY WHICH IS PUNISHABLE BY A FINE UP TO $10,000 PER VIOLATION AND UP TO EIGHT (8) YEARS OF IMPRISONMENT. Submit this properly completed application and the supporting course material to the following address: Indiana Secretary of State Securities Division 302 W. Washington St., Room E ­ 111 Indianapolis, Indiana 46204

State Form 53272 (R2 / 4-08)

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APPLICATION FOR APPROVAL OF LOAN BROKER ACADEMIC INSTRUCTION COURSE
State Form 53272 (R2 / 4-08) Approved by State Board of Accounts, 2007

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Todd Rokita Indiana Secretary of State Securities Division 302. W. Washington Street, E-111 Indianapolis, Indiana 46204 (317) 232-6681

Date (MM/DD/YYYY) Initial Application
1. VENDOR INFORMATION: (A) Full Legal Name
(B) Name of Contact Person

Renewal Application

(C) Address of Vendor

(D) City

(E) State

(F) Zip+4/Postal Code

(G) Telephone Number

(H) Fax Number

(I) E-Mail Address for Contact Person

(J) Web Address of Vendor

2. COURSE INFORMATION: (A) Title of Course
(B) Target Audience

(C) Has the Securities Commissioner previously approved this course? If Yes, when: (D) Type of Course In-house (one company only) Live

Yes

No

Open to any company or individual Video On-Line Final Exam Quizzes

(E) Method of Presentation (Please check one) Correspondence (F) Student Evaluation (Please check all that apply Assignments or Worksheets Other:

State Form 53272 (R2 / 4-08)

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3. TO BE COMPLETED IF A LIVE COURSE: (A) Total Minutes of Instruction (Excludes break, meal, and test time)
(B) Description of Materials Distributed (Check all that apply) Course Book Power Point Notes Other (describe in detail):

(C) Is the site for this course accessible to persons with disabilities?

Yes

No

4. TO BE COMPLETED IF A VIDEO COURSE: (A) Total Minutes of Instruction on Video
(B) Proctor or Leader in Room:

(C) Description of Materials Distributed (check all that apply) Course Book Power Point Notes Other (describe in detail):

5. TO BE COMPLETED IF A CORRESPONDENCE COURSE: (A) Total Pages of Material
(B) Description of Materials Distributed (check all that apply) Course Book Other (describe in detail):

6. TO BE COMPLETE IF AN ON-LINE COURSE: (A) Total Minutes of Timed Script (Example would be if streaming audio component included)
(B) Total Pages of Text (Example would be if each screen was printed)

(C) Description of Materials Distributed (check all that apply) Course Book Other (describe in detail):

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State Form 53272 (R2 / 4-08)

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7. COURSE INSTRUCTOR(S) INFORMATION (To be completed if a live or video course):
(A) Full Legal Name of Instructor: First Name Last name Middle name

Street address

City

State

Zip+4/Postal Code

Principal Occupation

Within the past ten (10) years have you been subject to a disciplinary proceeding? Within the past five (5) years have you been convicted of or plead guilty or nolo contendere ("no contest") in a domestic, foreign, or military court to any felony? (B) Full Legal Name of Instructor: First Name

YES YES

NO NO

Last name

Middle name

Street address

City

State

Zip+4/Postal Code

Principal Occupation

Within the past ten (10) years have you been subject to a disciplinary proceeding? Within the past five (5) years have you been convicted of or plead guilty or nolo contendere ("no contest") in a domestic, foreign, or military court to any felony? (C) Full Legal Name of Instructor: First Name

YES YES

NO NO

Last name

Middle name

Street address

City

State

Zip+4/Postal Code

Principal Occupation

Within the past ten (10) years have you been subject to a disciplinary proceeding? Within the past five (5) years have you been convicted of or plead guilty or nolo contendere ("no contest") in a domestic, foreign, or military court to any felony?

YES YES

NO NO

SUBMIT A RÉSUMÉ FOR EACH COURSE INSTRUCTOR, USE ADDITIONAL FORMS AS NEEDED
State Form 53272 (R2 / 4-08) Page 4 of 5

8. ACKNOWLEDGMENTS (A) I acknowledge that the Securities Commissioner may request additional information in consider the approval of this course; (B) I acknowledge that this course will be/is open to the Indiana Secretary of State, Securities Division for observation; (C) I affirm, under penalties for perjury, that the representation made in this application and in the attached documents hereto are true, accurate, and complete to the best of my knowledge. Printed Name and Title

Signature

Date (MM/DD/YYYY)

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State Form 53272 (R2 / 4-08)

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