Ref No. Rel No. C/R No. Date Proc.
STATE OF NEW JERSEY
DEPARTMENT OF BANKING and INSURANCE
LICENSING SERVICES BUREAU
PO Box 473
Trenton, NJ 08625
BRANCH APPLICATION
INDICATE TYPE OF LICENSE:
Motor Vehicle Installment Seller
Home Repair Contractor Pawnbroker
Check Casher
T
YPE OR PRINT CLEARLY
1. Name of Applicant:_______________________________________________________________________
D
/B/A or Trade Name (if applicable)_________________________________________________________
2. Principal address as it appears on license:
_____________________________________________________
________
___________________________________________________Reference No.___________________
3. A
ddress of branch office to be licensed(include, city, state, county & zip code)________________________
_________
________________________________________________________________________________
CERTIFICATION
I, the applicant, being duly sworn according to law depose and say that the answers set forth are true to the best
of my knowledge and belief. This application is made for the purpose of inducing the issuance of a banking
license and I understand that any information withheld or which represents a material misstatement will
constitute grounds for rejection of this application by the Commissioner of Banking and Insurance.
____________________________________________
Signature of Corporate President, Partner, Sole Proprietor
____
_____________________________________________
Date
Subscribed and sworn to before me at
__________________________________________________
t
his ______________day of_____________________20_____
__________________________________________________
(Official Title)
GENBRAPP212NJ
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