
# # # # #
No
# # # # #
TDI USE ONLY FPCARD: ナ
Texas Department of Insurance CO. ID: LIC.#:
Property & Casualty Program - Title Division, Mail Code 106-2T
PID: EXP:
333 Guadalupe
コ
P. O. Box 149104, Austin, Texas 78714-9104
ISSUE: RIDER: ナ
512-322-3482 telephone
コ
512-305-7426 fax
コ
www.tdi.texas.gov
R.R.#: OTHER: ナ
DSSOLFDWLRQ#IRU#WH[DV#HVFURZ#RIILFHUᄊV#OLFHQVH#
***ACTING AS AN ESCROW OFFICER BEFORE YOUR LICENSE IS ISSUED IS A VIOLATION OF §2652.001 AND IS SUBJECT
TO DISCIPLINARY ACTION INCLUDING FINES AND LICENSE DENIAL AND/OR REVOCATION (see Title Bulletin No. 164)***
INSTRUCTIONS
1. Applicant (and employer attorney if applicable) must complete Section A.
2. Sponsoring title agent/direct operation must complete Section B.
3. Licensing fee of $35.00 must be submitted.
4. Texas escrow officer's schedule bond must be attached, if needed.
(If bond is already on file, rider or endorsement must be attached).
5. Fingerprints and criminal history information ᄆ#see addendum regarding requirements
SECTION A -- ESCROW OFFICER IDENTIFICATION
Mr.
1. Name in full: Mrs. Last First Middle
Ms.
(No initials accepted) (No initials accepted)
2. Residence Address
City State Zip Phone No. ( )
3. E-Mail Address
(required for notification purposes)
4. Social Security Number 5. Texas Resident ナ Yes ナ
(Disclosure of Social Security Number is required by the Texas Family Code §231.302)
6. Date of Birth 7. Driver's License # State
(MM DD YYYY)
8. Marital Status
ナ Single ナ Married ナ Divorced ナ Widowed
-Li#|rx#dqvzhu#ᄈ\hvᄡ#wr#txhvwlrq#<d/#<e/#<f/#dqg2ru#<g/#|rx#pxvw#vxeplw#ruljlqdo# CERTIFIED copies of the indictment or
charging document, conviction, order deferring adjudication, judgment and conditions of probation from the appropriate
jurisdiction, for each and every crime or offense. You may also include letters of recommendation on your behalf. Please
provide full information with dates and details on a separate sheet of paper. Application processing will be suspended
until the details are received and a review is completed. If certified documents have been previously submitted to
the department, please do not resend.
9. Excluding traffic violations and first offense DWI:
a. do you currently have any pending misdemeanor or felony charges (by indictment,
information, or any other instrument) filed against you in Texas, any other state, or by
the federal government? *ナ
YES ナ NO
b. have you ever been convicted of any misdemeanor or felony offense in Texas, any other
state, or by the federal government? *ナ YES ナ NO
c. have you ever had adjudication deferred on any misdemeanor or felony charge or offense
in Texas, any other state, or by the federal government? *ナ YES ナ NO
d. have you ever served any period or probation for any misdemeanor or felony offense in
Texas, any other state, or by the federal government? *ナ YES ナ NO
PC132 Rev. 08/11 Page 1 of 4