Section 17419.

On and after January 1, 1992, any person seeking employment with an escrow agent shall complete an employment application on or before the first day of employment which includes, at least, the following information. A copy of the employment application shall be forwarded to the commissioner on or before the first day of the applicant's employment. Persons required to file a statement of identity and questionnaire pursuant to subdivision (g) of Section 17209 or Section 17212.1 are not required to file the employment application set forth in this section. Each person completing the employment application shall be given the notice required by the Information Practices Act (Section 1798.17 of the Civil Code), copies of which may be obtained from the commissioner. Nothing in this section shall limit an escrow agent from requesting additional information from an applicant.

STATEMENT OF IDENTITY
AND EMPLOYMENT APPLICATION

Name of Escrow Company:

Escrow Agent License Number:

1. Exact Full Name:
 

(Please Print or Type)First NameMiddle NameLast Name

(Do not use initials or nicknames)

 Title of position to be filled in connection with the preparation of this employment application.
 

 2. Employment for the last 10 years:

From	To	Employer Name and Address	Occupation and Duties
_____	Present	_____	_____
_____	_____	_____	_____
_____	_____	_____	_____
_____	_____	_____	_____
_____	_____	_____	_____
_____	_____	_____	_____
_____	_____	_____	_____
_____	_____	_____	_____
_____	_____	_____	_____

 NOTE: Attach separate schedule if space is not adequate.

 3. Residence addresses for the last 10 years:

From	To	Street	City	State
_____	Present	_____	_____	_____
_____	_____	_____	_____	_____
_____	_____	_____	_____	_____

 NOTE: Attach separate schedule if space is not adequate.

 4. Have you ever been named in any order, judgment or decree of any court or any governmental agency or administrator, temporarily or permanently restraining or enjoining you from engaging in or continuing any conduct, practice or employment?

( ) Yes	( ) No
If the answer is "Yes," please complete the following: _____
Date of Suit:
Location of Court (City, County, State):
Nature of Suit:
Note: Attach a certified copy of any order, judgment, or decree.

 5. Have you ever been refused a license to engage in any business in this state or any other state, or has any such license ever been suspended or revoked?

( ) Yes	( ) No
If the answer is "Yes," please complete the following: _____
State: Title of State Department: Nature of License and Number: Note: Attach a certified copy of any order, judgment, or decree.

6. Have you ever been convicted of or pleaded nolo contendere to a crime other than minor traffic citations that do not constitute a misdemeanor or felony offense?
	NOTE: A conviction is a plea or verdict of guilty or a conviction following a plea of nolo contendere. A conviction also includes an order granting probation and suspending the imposition of sentence, notwithstanding a subsequent order pursuant to Sections 1203.4 or 1203.4a of the Penal Code permitting the person to withdraw his or her plea of guilty, or dismissing the accusation, information, or indictment.

_____	( )  Yes	( ) No
If the answer is "Yes," please complete the following: _____
Date of Case:
Location of Court (City, County, State):
Nature of Case:
Note: Attach a certified copy of any order, judgment, or decree.

 7. Have you ever been a defendant in a civil court action other than divorce, condemnation or personal injury?

_____	( )  Yes	( ) No
If the answer is "Yes," please complete the following:		_____
Date of Suit:
Location of Court (City, County, State):
Nature of Suit:
Note: Attach a certified copy of any order, judgment, or decree.

8. Have you ever changed your name or ever been known by any name other than that herein listed?
	(Including a woman's maiden name)

_____	( ) Yes	( ) No
If so, explain. Change in name through marriage or court order should also be listed.
EXACT DATE OF EACH NAME CHANGE MUST BE LISTED.

 9. Have you ever done business under a fictitious firm name either as an individual or in the partnership or corporate form?

( ) Yes		( ) No
If the answer is "Yes," set forth particulars:

 10. Have you ever been a subject of a bankruptcy or a petition in bankruptcy?

( ) Yes

( ) No

 If the answer is "Yes," give date, title of case, location of bankruptcy filing:

 

 

 

 11. Have you ever been refused a bond, or have you ever had a bond revoked or canceled?

( ) Yes		( ) No
If the answer is "Yes," give details:
12.?In what capacity will you be employed?
(e.g., Clerk, Escrow Officer, Receptionist, etc.)		_____ _____

 13. Do you expect to be a party to, or broker or salesperson in connection with, escrows conducted by the escrow company which is employing you?

( ) Yes		( ) No
If the answer is "Yes," please explain:		_____
NOTE: Attach separate schedule if space is not adequate.

VERIFICATION

I, the undersigned, state that I am the person named in the foregoing Statement of Identity and Employment Application; that I have read and signed the Statement of Identity and Employment Application and know the contents thereof, including all exhibits attached thereto, and that the statements made therein, including any exhibits attached thereto, are true.

Any person who knows or should have known of a violation of this section shall immediately report the violation in writing to the commissioner.

_____	I certify/declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
_____	Executed at
_____	(City)
_____
_____	(County)(State)
_____	thisday of, 20__.
_____
_____	(Signature of Declarant)

(Amended by Stats. 2007, Ch. 130, Sec. 94. Effective January 1, 2008.)