NON-BANK ATM REGISTRATION

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

FOR OFFICE USE ONLY

DATE RECEIVED _________________________

AMOUNT RECEIVED ______________________

CASH [  ]  CHECK [  ] CHECK #: ____________

In accordance with the provisions of 32 M.R.S.A., 
c. 80, sub-c. III, the Cash-Dispensing Machines 
Established By Non-Banks Act, application is 
hereby made to establish or operate a cash 
dispensing or ATM machine.

1.  	Operator of Cash-Dispensing Machine [Note: This is the person or company which “owns, leases or otherwise legally controls” the terminal.]

a)	Name or Trade Name __________________________________________________________

b)	Address _____________________________________________________________________
Street			City		State		County		Zip Code

c.  Telephone Number (               ) ____________________________________________________

d.	Contact Person ___________________________ E-Mail Address _______________________

2.  	Location of Cash-Dispensing Machine

a.	Name or Trade Name __________________________________________________________

b.	Address _____________________________________________________________________
Street				City		State		Zip Code

c.  Telephone Number (               ) ____________________________________________________

d.	Contact Person ___________________________ E-Mail Address _______________________

3.  	Actual or Planned Date of Operation of Cash-Dispensing Machine_______________________

4.  	What Types of Transactions Can the Terminal Perform?

•	Dispense Cash
•	Determine Account Balances
•	Transfer Funds Within an Institution
•	Other (Please Specify):   ____________________________________________
			________________________________________________________________

5.   Fee Assessed At Cash Dispensing Machine Per Transaction:  $ _________________________

6.   Processor Of Transactions [Note: This is the person or business that “electronically acquires financial data from a cash-dispensing machine and relays that data to a network.”]

a.	Name or Trade Name __________________________________________________________

b.	Address _____________________________________________________________________
Street				City		State		Zip Code

c.  Telephone Number (               ) ____________________________________________________

d.	Contact Person __________________________ E-Mail Address ________________________

7.   Servicing Agent  [Note: This is the person or company which “contracts with an operator to provide customer relations, financial record keeping or similar service.”]

a.	Name or Trade Name __________________________________________________________

b.	Address _____________________________________________________________________
Street				City		State		Zip Code

c.  Telephone Number (               ) ___________________________________________________

d.	Contact Person ___________________________ E-Mail Address _______________________

8.   Toll Free Servicing Number.  Maine law requires disclosure of a “24-hour, toll-free number where a consumer may direct inquiries or complaints.”  This number will be listed on the state registration sticker.  What number do you want listed?  __________________________________ 

Whose number is that?  ___________________________________________________________

9.   Registration Fees (Checks made payable to “Treasurer, State of Maine”)

For an operator’s first cash-dispensing machine:		$ 50.00

For additional terminals placed by the same operator:	$ 25.00

									$______________ Total

(Maine law [5 M.R.S.A. §130 (1991)] requires assessment of $20.00 for any check returned by your bank for insufficient funds.)

Dated this __________________day of ___________________, 200________

Signature: ___________________________________ Title: ________________________________

Printed Name:  ________________________________

NOTICE REGARDING PUBLIC INFORMATION
	This application is a public record for purposes of Maine’s Freedom of Access Law, 1 MRSA §401, et seq.  Public records must be made available to any person upon request.  Information that you supply as part of this application (except your Social Security number and date of birth) is public information.  Other licensing records to which this information may later be transferred are also considered public records.  Where permitted by law, your company’s name, license number, mailing address and other information listed on this application may be posted on the State’s website.