Fillable Printable Applciation for Check Cashier Permit - California
Fillable Printable Applciation for Check Cashier Permit - California
Applciation for Check Cashier Permit - California
STATE OF CALIFORNIA DEPARTMENT OF JUSTICE
BCIA 4130
(Orig. 11/1994; Rev. 09/2012)
APPLICATION FOR CHECK CASHER PERMIT
PAGE 1 of 2
DOJ USE ONLY
A. OWNERSHIP INFORMATION: List all partners or corporate officers and shareholders with 10% or more ownership as
indicated on the Statement of Information filed with the Secretary of State.
Type of Ownership (Check one)
Sole Proprietor Partnership Corporation
Name Last
First Middle
Title
Male
Female
Date of Birth
Social Security Number
Driver License or CA ID
Home Telephone Number
E-mail Address
Address City State Zip Code
PARTNERS/OFFICERS/SHAREHOLDERS
Name (Last, First, Middle)
Title
Date of Birth
Social Security Number
Name (Last, First, Middle)
Title
Date of Birth
Social Security Number
Name (Last, First, Middle)
Title
Date of Birth
Social Security Number
ATTACH ANOTHER SHEET FOR ADDITIONAL PARTNERS/OFFICERS/SHAREHOLDERS.
CHECK BOX IF ANOTHER SHEET IS USED.
B. BUSINESS INFORMATION: All information requested in this section, including business bank information, must be
provided.
Business Name (Doing Business As) Main Type of Business
Date of Ownership
Month Year
Address City State Zip Code County
Mailing Address (if different than above) City State Zip Code Business Phone Number
Name of Business Bank Address of Business Bank
ATTACH ANOTHER SHEET FOR ADDITIONAL BUSINESS LOCATIONS.
CHECK BOX IF ANOTHER SHEET IS USED.
Completed:
OCA #:
Fee:
Received:
California Department of Justice
Bureau of Criminal Information and Analysis
Check Casher Permit Program (CCPP)
P.O. Box 903387
Sacramento, CA 94203-3870
(916) 227-3250
Privacy Notice
The information on this form is requested by the State of California, Department of Justice (DOJ), California Justice Information Services (CJIS) Division, Applicant Information and Certification Branch, for the purpose of applying to
operate a check casher business in the State of California. The maintenance of the information collected on this form is authorized by Civil Code section 1789.37 (a) and Check Cashier Regulations Title 11, Division 1, Chapter 13.5. All
information requested on this form is mandatory. Failure to provide the requested information will result in a delay in processing and/or denial of the application. Information provided on this form may be disclosed to federal, state, city,
and county government or law enforcement agencies.
Pursuant to Civil Code Section 1798.30 et seq., individuals have the right [with some exceptions] to access records containing the personal information about them that is maintained by the agency. The Check Casher Permit Program is
the agency official responsible for the system of records that maintains the information provided on this form. For more information regarding the location of your records and the categories of any persons who use the information in
those records, you may contact the Bureau of Criminal Information and Analysis, Check Casher Permit Program, Department of Justice, at P.O. Box 903387, Sacramento, CA 94203-3870, or via telephone at (916) 227-3250.
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STATE OF CALIFORNIA DEPARTMENT OF JUSTICE
BCIA 4130
(Orig. 11/1994; Rev. 09/2012)
APPLICATION FOR CHECK CASHER PERMIT
PAGE 2 of 2
D. ADDITIONAL INFORMATION:
1. Have any parties to this application ever been convicted of a criminal felony or misdemeanor offense for any
reason whatsoever (excluding MINOR traffic violations)?
YES NO
2. Are any parties to this application NOT in compliance with a judgement or court order for family support?
YES NO
If any of your answers to D-1 or D-2 was "YES", provide the following details where applicable. If two or more parties to
this application answered "YES" to D-1 or D-2, each must complete a separate Section D.
Name of party:
Type and nature of violation(s):
City and state of violation(s):
Sentencing court:
Date of incarceration:
Dates of probation:
Conditions of probation:
Name, address, and phone number of probation officer:
E. CERTIFICATION:
I certify under penalty of perjury, pursuant to the laws of the State of California, to the truth and accuracy of all statements,
answers, and representations made in the foregoing application, including all supplementary statements.
Signature of Owner/Partner/Corporate Officer
Title
Date
MISREPRESENTATION OR FAILURE TO DISCLOSE REQUESTED INFORMATION ON THIS
APPLICATION IS CAUSE FOR DENIAL OR REVOCATION OF PERMIT.
Partnership/Corporate Address
City
State
Zip Code
Phone NumberPartnership/Corporate Name
If "Yes", complete the following:
NoYes
Is the partnership or corporate name different from the business name?
C. PARTNERSHIP/CORPORATE INFORMATION:
