***BRANCH APPLICATION***

BAD CHECK DIVERSION PROGRAM REGISTRATION APPLICATION

STATE OF MAINE
BUREAU OF CONSUMER CREDIT PROTECTION
35 STATE HOUSE STATION
AUGUSTA, MAINE 04333-0035
TEL: (207)624-8527
FAX: (207)582-7699

DATE APPLICATION REC’D:  			

AMOUNT FEE REC’D:  				
CASH [     ]     CHECK [     ]

CHECK NO:  					

CHECKED BY:  					

In accordance with the provisions of 32 M.R.S.A., §11013-A et seq.,
application is hereby made for a registration as a Bad Check Diversion 
Program.

1.	FULL TRADE NAME OF PRIVATE ENTITY OPERATING DIVERSION PROGRAM (INCLUDING D/B.A):

	____________________________________________________________________				

2.	ADDRESS OF DISTRICT ATTORNEY’S OFFICE SPONSORING PROGRAM:
_________________________________________________________________________________________
____________________________________________________ TELEPHONE: (___)____________________

3.	ADDRESS OF HOME OFFICE FOR DIVERSION PROGRAM OPERATOR: ____________________________

	_____________________________________________________ TELEPHONE: (___)___________________

HOME OFFICE LICENSE #                                                EXPIRES       ____________________

4.	Attach to the application a résumé of the person who will be actively in charge of the branch office, indicating previous experience or qualifications that bear on the issue of competency in operating a bad check diversion program.

5.	      Identify the financial institution where the trust account will be maintained, and the numbers assigned
	by the institution to the account: 
	__________________________________________________________________________________________

6.			  Include the name, title, address, and telephone number of the person to contact for the scheduling of 		     routine compliance examinations: ____________________________________________________________
	     __________________________________________________________________________________________
	     __________________________________________________________________________________________	

7	If the existing license for your company's home office expires in less than 12 months, include an application fee for the branch office in the amount of $150.   If the home office license expires in more than 12 months, include a branch application fee of $300.  Your branch office license(s) will be scheduled to expire on the same date as your home office license.  Check is payable to Treasurer, State of Maine.

8.		For applicants seeking to maintain their books and records outside of the State of Maine, please include 	on a separate sheet a statement from an officer of the applicant indicating the applicant’s willingness to 	make such records available upon request.

Maine law [5 M.R.S.A. §130 (1991)] requires assessment of $20 for any check returned by your bank for insufficient funds.

(If a Corporation, affix
Corporate seal here)
By:____________________________________
									Title: __________________________________

STATE OF ______________________________

County 
of:                                      , ss.							                                  , 200_____

Personally appeared the above-named                                                  and made oath to the truth of the statements subscribed,

Before me, 

							          	             	____________                                       
                                                             Notary Public/Justice of the Peace  

PLEASE MAIL YOUR APPLICATION ADDRESSED AS FOLLOWS:

REGULAR MAIL (US Postal Service):				EXPRESS/OVERNIGHT MAIL (Other Than USPS):

STATE OF MAINE						BUREAU OF CONSUMER CREDIT PROTECTION
BUREAU OF CONSUMER CREDIT PROTECTION		GARDINER ANNEX
35 STATE HOUSE STATION					76 NORTHERN AVENUE
AUGUSTA, ME 04333-0035					GARDINER, ME 04345