The undersigned does hereby apply for membership in the Collateral Loanbrokers Association of New York State and agrees that if this application is accepted they will abide by the Constitution and By-Laws of the Association and all amendments, which may be made thereto.
The undersigned further certifies that he is a citizen of the United States and of good moral character, or if the applicant is a corporation, that its officers, directors and majority stockholders are citizens of the United States and of good moral character.
Dated: ___/___/___ ____________________________
Name of Business Owner
____________________________
Trade Name
In connection with this application for membership, the applicant represents the following data to be true and accurate:
1. Address of business: ____________________________________
___________________________zip______
phone: _________________ fax: ________________ E-mail: ___________________
2. Date of commencement of business at present address: ____/_____/___
3. How many years in the pawnbroking business: ________________
4. Names of officers and/or principals and percentage of ownership:
____________________________________%
____________________________________%
____________________________________%
5. License # and issuing agency: __________________________________
6. Sponsor who recommended that you join the association: ____________________
Approved: ________________
Chairman Membership Committee
