STATE OF MAINE
BUREAU OF CONSUMER CREDIT PROTECTION
PAWNBROKER REGISTRATION APPLICATION
35 STATE HOUSE STATION
AUGUSTA, ME 04333-0035
TELEPHONE: (207) 624-8527 FAX: (207) 582-7699
FOR OFFICE USE ONLY

DATE APPLICATION REC’D:  ____________________________

AMOUNT FEE REC’D:  	          ____________________________

CASH [     ]     CHECK [     ]

CHECK NO:     ________________________________________

CASH NO: _________________________________________			
In accordance with the provisions of the
Maine Consumer Credit Code, this
notification is hereby filed with the
superintendent of the Bureau of Consumer
Credit Protection.

NOTE:  Please complete all the following information. Failure to do so will delay the review of your application until the requested information is provided.
1.	Business Name: _____________________________________________________________
Physical Address: ____________________________________________________________
Mailing Address: ____________________________________________________________
City: _______________________________ State: _______________ Zip: ______________
Telephone: _____________________________ Fax: _______________________________
Company Web Address: ______________________________________________________
D/B/A: __________________________________ FEIN/SS# _________________________
Please enclose a copy of your municipal pawn shop license.
Is the pawn shop currently operating under this name?	[    ] Yes	[    ] No
If yes, please indicate start date: _____ / _____ / _______
If not, what is your proposed start date? _____________________________________________
Business structure:	[    ] Proprietorship	[    ] Partnership	[    ] Corporation
2.	Owner’s Name(s): ___________________________________________________________
___________________________________________________________________________
Telephone(s): _______________________________________________________________
General Manager’s Name: _______________________ Telephone: ____________________
Designated person for consumer complaints: ______________________________________
Telephone: _______________________ E-mail: ___________________________________
3.	Provide the location of records of pawn transactions:

Physical Address: ____________________________________________________________

Mailing Address: ____________________________________________________________

4.	Are you currently operating any other pawn shops within the state of Maine? [    ] Yes	  [    ] No
If yes, please list names and locations (attach sheet if necessary): ______________________
___________________________________________________________________________
5.	Original amount financed (consumer credit pawn transactions) in Maine during the past calendar year.  

A.	Amount Financed (Pawn Transactions):  $ 					

6.	Fees Due: 

A.	Volume Fee (See Schedule on next page): $ 					
B.	Annual Notification Fee:  $ 					$20.00		
C.	Total Fees Due (Sum of A & B):  $						

	I hereby certify that the statements in the foregoing report are true and correct to the best of my knowledge and belief
Dated at: __________________ this _______________ day of ______________, __________

							__________________________________
							Signature
							__________________________________
							Name Typed or Printed Legibly
							__________________________________
							Title

If you have any questions about completing this form, call the Bureau at (207) 624-8527

RETURN CHECKS WITH PROPER FEES TO:
Bureau of Consumer Credit Protection, #35 State House Station, Augusta, ME 04333-0035
All checks must be payable to “Treasurer, State of Maine”

SCHEDULE OF VOLUME FEES
AMOUNT FINANCED	FEE				AMOUNT FINANCED	FEE
$ 1 TO $100,000		$25				$500,001 TO $600,000	$150
$100,001 TO $200,000	$50				$600,001 TO $700,000	$175
$200,001 TO $300,000	$75				$700,001 TO $800,000	$200
$300,001 TO $400,000	$100				$800,001 TO $900,000	$225
$400,001 TO $500,000	$125				$900,001 TO $1,000,000	$250*
*If your volume was in excess of $1,000,000 you can readily calculate the fee by extending the schedule