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DEPARTMENT OF
AUDIT
DIVISION OF BANKING
(307)
777-7797 Fax (307) 777-3555 Email:
marlene.aitchison@wyo.gov
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Matthew
H. Mead
Governor
Michael
Geesey
Director
Jeffrey
C. Vogel
Commissioner
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APPLICATION FOR LICENSE UNDER
WYOMING MONEY
TRANSMITTERS ACT,
W.S. 40-22-101 through W.S. 40-22-129
(Application Fee $1500.00)
Business Name and Trade
Name (if applicable)
___________________________________________________
State of
Incorporation ____________________ Date of
Incorporation______________________________
Business Address
___________________________________________________________________________
City, State, Zip Code
_________________________________________________________________________
Manager or Officer in
charge of Wyoming activities
_________________________________________________
Phone Number ______________________________ Fax Number _____________________________
E-mail
Address____________________________________ Federal EIN _____________________________
Web Site:
_________________________________________________________________________________
Name of Applicant (if
applicable)
_______________________________________________________________
Birth Date _____________________________ Social Security Number ___________________________
Residence Address
__________________________________________________________________________
City, State, Zip Code ____________________________________ Phone Number
____________________
E-mail Address ________________________________________
Location of Business Records
_________________________________________________________________
City, State, Zip Code ____________________________________ Phone Number _____________________
The
commissioner is authorized for good cause shown, to waive any requirements of W.S. 40-22-108 with respect to any license application or
to permit a license applicant to submit substituted information in its license
application in lieu of the information required by W.S.
40-22-108.
All information or reports
obtained by the commissioner from an applicant, licensee or authorized delegate
are confidential, pursuant to W.S. 40-22-117.
THE FOLLOWING INFORMATION MUST BE REFERENCED AND ATTACHED TO
ALL APPLICATIONS
Please initial
checklist where appropriate.
For all appendices
initialed as “Not Applicable,” please provide a written explanation of why they
are not applicable.
1. History
of any criminal convictions and material litigation for the 5 years prior to
the date of application.
Attached
as (Appendix A)________ Not Applicable________
2. Description of: Attached as
(Appendix B)________
Activities conducted by
applicant,
History of operations, and
Business activities in
which the applicant seeks to be engaged in Wyoming
3. A list of proposed authorized delegates in Wyoming.
Attached as (Appendix C)________ Not Applicable________
4. A
sample authorized delegate contract, if applicable.
Attached as (Appendix D)________ Not Applicable________
5. A sample form of payment instrument, if applicable.
Attached as (Appendix E)________ Not Applicable________
6. Location(s)
where applicant and authorized delegates propose to conduct activities in Wyoming.
Attached
as (Appendix F)________ Not Applicable________
7. Names
and addresses of clearing banks on which payment instruments will be drawn or
through which the payment instruments will be payable.
Attached
as (Appendix G)________ Not Applicable________
8. Documents establishing a minimum net worth of $25,000 pursuant to
W.S. 40-22-105.
Attached as (Appendix H)________
9. A security
device, not to exceed $500,000, as provided for in W.S.
40-22-106(a), or a listing of other investments to be placed on deposit in
accordance with W.S. 40-22-106(b).
Attached
as (Appendix I)________
10. A
list of states where currently, or previously, licensed as a money
transmitter. Also, if you have had a
money transmitter license denied, revoked, or suspended by any state, please
list details.
Attached as (Appendix
J)________ Not Applicable________
11. The
dollar amount and number of payment instruments outstanding as of June 30, 2008
in the United States and the State of Wyoming.
(United
States)
Number___________ Amount
$_____________________________
(Wyoming) Number___________ Amount $_____________________________
12. A
list of the type and amount of the permissible investments of not less than the
aggregate face amount of all outstanding payment instruments and stored value
issued or sold by the licensee in the United States required by W.S. 40-22-107.
Attached as (Appendix K)________
13. The
non-refundable application fee of $1500.00.
14. If the applicant is a corporation or other
corporate structure the applicant must provide the following information. If not, then skip to question 15.
A. Relating to the applicant's
corporate structure:
Attached as (Appendix L)________
State of incorporation,
Date of incorporation,
Certificate of good standing from state of incorporation, and
Description of corporate structure:
Type of corporate structure (i.e. Incorporated, LLC,
etc.) ______________________
Identity of the parent of the applicant,
Identity of each subsidiary of applicant, and
Stock exchanges where applicant, parent, and subsidiaries
are publicly traded.
B. For each executive
officer, key shareholder, and officer or manager in charge of licensed
activities:
Attached as (Appendix M)________
Name,
Business address,
Residence address, and
Employment history for the 5 years prior to the date of
application.
C. For each executive officer,
and key shareholder:
Attached as (Appendix N)________ Not Applicable________
History of material litigation for 5 years prior to date of
application and
History of any criminal convictions for 5 years prior to the
date of application
D. Financial Data:
Complete the applicable (i, ii, or iii):
Attached as (Appendix O)________
i. Copies of audited financial statements for
the current year and the preceding 2 years, including a:
Balance sheet,
Statement of income or
loss,
Statement of changes in
shareholder equity, and
Statement of changes in
financial position
ii. If applicant is a wholly owned subsidiary
of a corporation publicly traded in the United States:
Consolidated audited financial
statements for the current year and the immediately preceding 2 year period, or
the parent corporation's Form 10K reports filed with
the United States Securities and Exchange Commission for the preceding 3 years
may be submitted with the applicant's unaudited financial statements.
iii. If applicant is
a corporation publicly traded outside the United States:
Similar documentation
filed with the parent corporation's non-United States regulator may be
submitted with applicant's unaudited financial statements.
E.
Copies of filings, if any, made with the United States Securities
and Exchange Commission, or with a similar regulator outside the United States,
not more than 1 year prior to the date of filing of the application. Attached as (Appendix P)________ Not
Applicable________
15. If the applicant is not a
corporation, the applicant must provide the following information.
A. For each principal
and each person who will be in charge of the applicant's licensed activities:
Attached as (Appendix Q)________
Name,
Residence address,
Business structure (sole proprietorship, partnership etc.)
___________________________
Business addresses,
Personal financial statement for the 5 years prior to the date
of the application, and
Employment history for the 5 years prior to the date of the
application
B. Documentation indicating the place and date
of the applicant's registration or qualifications to do business in Wyoming. Attached as
(Appendix R)________ Not Applicable________
C. For each individual having an ownership
interest in the applicant, and each individual who exercises supervisory
responsibility with respect to the applicant's activities the:
Attached as (Appendix S)________ Not
Applicable________
History of material litigation for 5 years prior to the date of
application and
History of any criminal convictions 5 years prior to the date of
application
D. Financial Data:
Attached as (Appendix T)________
Copies
of the applicant's audited financial statements for the current year and, if
applicable,
for the preceding 2 years, including a:
Balance sheet,
Statement of income or
loss, and
Statement of changes in financial position
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State of , County of ,
ss.
I HEREBY
CERTIFY that, on this ______ day of ,
20_____, the undersigned has/have executed the foregoing Application for and
on behalf of the Applicant, being duly authorized to do so; and
further that the information and statements contained in the
foregoing Application, including all exhibits and other documents attached
thereto and all other information filed therewith, all of which are made a
part of the foregoing Application, are correct, true, accurate and complete; and
further that the Applicant knows and understands that, if the
Applicant has knowingly made a false statement of a material fact in this
Application or in any documentation provided to support the foregoing
Application, then the foregoing Application must be denied and the Applicant
may be subject to criminal penalties for perjury under W.S.
6-5-301 and/or W.S. 6-5-303.
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Name of
Applicant (leave blank if individual)
By:
Authorized Signatory to
sign for Applicant
Printed/Typed Name (and
Title, if applicable) of Signatory
By:
Authorized Signatory to
sign for Applicant
Printed/Typed Name (and
title, if applicable) of Signatory
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Acknowledgement
State of )
) ss.
County of )
The
foregoing Application for a Money Transmitters License
was acknowledged before me by ________________________
and
by _
on
this____ day of ________, 20_____.
Witness
my hand and official seal.
(SEAL)
Notary
Public
My
commission expires:
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