1.

Name of immigration service provider:

Address, City, Zip Code:

Area Code and Telephone:

2.

Legal description of immigration service provider (i.e., corporation, partnership, assumed name, etc.):

3.

Name, address and telephone number of individuals authorized to accept service of process on behalf of the immigration service provider.

4.

Name, address and telephone number of any and all persons who directly or indirectly own or control 10% or more of the immigration service provider's business. (If additional space is needed, attach listing.)

5.

Malpractice Insurance and/or Surety Bond Information.

Please check one of the following, and complete relevant sections below:

____  I have Malpractice Insurance ___  I have a Surety Bond

A.        MALPRACTICE INSURANCE INFORMATION

1.         Name, address, telephone of Malpractice Insurance

            Carrier:

2.         Policy No.:

3.         Policy Amount:

4.         Expiration Date:

B.        SURETY BOND INFORMATION

1.         Name, address, telephone of Bonding Company:

2.         Bond No.:

3.         Bond Amount:

4.         Expiration Date:

6.         Has there, during the existence of the immigration service provider's business operation,  ever been any litigation or complaint filed against it by a local or governmental authority of the State of Illinois, any other state, or the United States, relating to the business operations of the registering immigration service provider?

      yes        no

7.         If the answer to question 6 above is "no," complete and notarize the following statement:

I,                             , under oath, do hereby affirm there has been no litigation or complaint filed against                              (name of provider) by any local or governmental authority of the State of Illinois, any other state, or the United States.

Signature of Affirmant, Title or Official Capacity

Subscribed and affirmed to before me this          day of                            ,     .

NOTARY PUBLIC

(Seal)

8.         If the answer to question 6 above is "yes," answer the following:

i)     Name and address of the plaintiff or complainant.

ii)     Name and address of the court or governmental office where the lawsuit or complaint was filed.

iii)    Filing number of the lawsuit or complaint brought against the immigration service provider.

iv)    Date when the lawsuit or complaint was filed

v)     A brief description of the nature of the lawsuit or complaint.

(Attach additional pages if necessary.)

vi)    What outcome (i.e., trial, settlement)?

9.         If the answer to question 6 above is "yes," complete and notarize the following statement:

I,                       , under oath, do hereby affirm the foregoing statements and affirm any and all attachments are true and correct.

Signature of Affirmant,  Title or Official Capacity

Subscribed and affirmed to before me this

           day of                          ,      .

NOTARY PUBLIC

(Seal)