BIOGRAPHICAL REPORT

General Information and Instruction

A complete Biographical Report must be filed by each proposed director, executive officer, and principal
shareholder. The Texas Department of Banking (Department) may request additional information or
clarification of any information submitted. The accuracy and completeness of the information may be verified
by the Department.
All Biographical Reports must be printed or typed. Questions must be answered completely and may not
be left blank. If the answer is "None" or "Not Applicable," so state. If an item of information is unknown to
you, so state. Unless otherwise noted, questions should be answered in the spaces provided; additional
pages may be inserted, if necessary. Information on inserted pages must be keyed by number and
letter to the appropriate questions.
An inaccurate or incomplete report may be rejected, could result in a delay in processing the application, and
could lead to denial.
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___________________________________________________ : NAME OF REGULATED/PROPOSED ENTITY
Provide an answer for all questions. If more space is needed, attach additional sheets if necessary. Clearly
identify each response.
I. GENERAL
Name: __________________________ ___________________________ ______________________________
(First) (Middle) (Last)
Aliases, Nicknames, and Previous Names: ________________________________________________________
Residence Address: __________________________________________________________________________
(Street Address)
______________________________________ ___________________________ ________________________
(City) (State) (Zip Code)
Residence Telephone: Email Address: _____________________________ __________________________
Marital Status: ________________________________ ___________________ If married, full name of spouse:
Date of Birth: Place of Birth: ____________________ _______ __________________ __________________
(City) (State) (Country)
Are you a U.S. Citizen? YES NO
Note: If the answer is No, furnish complete details on a separate sheet. Include copies of documents that
will support your alien status. Include passport number, Home Country ID No., and Immigration File No., if
applicable. If you were not born in the U.S., provide a copy of your naturalization certificate or passport.
Driver License Number: ______________________ _______________________________ State of Issuance:
Social Security Number: Federal Tax ID Number: ______________________ __________________________
Proposed Position: Director Executive Officer-Title: _____________________
Principal Shareholder Other: ___________________________
Address the following using a separate attachment for each section.
II. RESIDENCES
List all principal residences you have had over the past ten (10) years in chronological order, starting with
your current residence.
III. EDUCATION
Account for all schools, colleges, and universities attended beyond 12
th
grade. Include the following
information:
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Name of school;
Address of school;
Dates of attendance; and
Degree received.
IV. EMPLOYMENT
A. Provide the following information in chronological order, starting with your most recent position,
regarding your employment, self-employment, or period of unemployment during the past ten (10)
years:
Name of employer;
Employers address;
Dates employed;
Title and job description;
Name and title of supervisor;
Description of the business;
Reason for leaving; and
B. If you have been discharged or asked to resign from any past employment, including a less than
honorable discharge from military service, provide the following information:
Name of employer;
Employers address;
Title or position;
Date of discharge/resignation; and
Explanation for discharge/resignation.
C. List any bank, trust company, or regulated institution for which you are or have been a director,
executive officer, or principal shareholder. Include percentage of ownership, position held or
relationship, address of entity, and beginning and ending dates of position held or relationship.
D. If you are a proposed director or executive officer of the regulated or proposed entity, provide
complete details of your banking or related experience. Include information on positions held in
banks, savings institutions, credit unions, or trust companies, number of employees supervised,
lending authority, etc., and indicate how the institution performed in the area for which you were
responsible.
E. If you are involved in the organization of a proposed new state bank or trust company, provide
information on your specific role.
F. Present any other information you believe is important in determining your personal qualification as a
proposed director or executive officer of a regulated or proposed entity.
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V. OCCUPATIONAL AND PROFESSIONAL LICENSES
A. List all your occupational, vocational, or professional licenses (Examples: Attorney, Physician, C.P.A.,
Teacher, etc.), including those surrendered, which have been issued by an agency of ANY state, the
U.S. federal government, or the government of any other country. Include the following information:
Type of license;
Name of licensing agency;
Address of licensing agency
Original issuance date;
Expiration date; and
Amount of time devoted to the licensed activity.
B. List all your occupational, vocational, or professional licenses that have been refused, denied, revoked,
or suspended by an agency of ANY state, the U.S. federal government, or the government of any other
country. Include the following information:
Type of license;
Name of licensing agency;
Address of licensing agency;
Type of action; and
Date of action.
VI. CRIMINAL HISTORY
A. Provide information regarding any arrest, charge, indictment, or conviction on you by any law
enforcement agency (including a conviction where the record was expunged), other than minor traffic
violations. Indicate the nature of the charge, date, jurisdiction and location, and resolution or
disposition of the matter.
B. Provide information regarding any charge, indictment, or conviction by any law enforcement agency,
against any company with which you are or were associated as a director, executive officer, or principal
shareholder. Indicate the name of the business, your interest, the nature of the charge, date,
jurisdiction and location, and resolution or disposition of the matter.
C. Describe any lawsuit, formal or informal investigation, examination, or administrative proceeding
against you or any company with which you are or were associated by any governmental entity,
government regulatory agency, or professional organization that may result in or resulted in any
penalty (including, but not limited to, any sanction, fine, loss of right or benefit, order to pay damages,
forfeiture of property interest, revocation of license, etc.), agreement, undertaking, consent, judgment,
or order imposed. Give the name of any organization involved, the nature of lawsuit, charge, or
proceeding, resolution or disposition of the matter, and the date of any relevant event.
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If YES to any of the following questions, provide details on a separate attachment.
1. Has an order, injunction, or judgment, whether or not final, been entered against you or any company
with which you are or were associated in a civil action on account of fraud, misrepresentation, or
deceit?
YES NO
2. Have you been sued in a civil action?
YES NO
3. Have you or any company with which you are or were associated filed a petition under any chapter
Bankruptcy Code or had an involuntary bankruptcy petition filed against you or the company?
YES NO
4. Have you or has your spouse been convicted of a felony criminal offense under state or federal law, or
a similar law of a foreign country, related to deception, dishonesty, or defalcation?
YES NO
5. Do you owe the Department, any state, or federal government any delinquent fees, assessments,
administrative penalty, or other amount imposed by state or federal court order?
YES NO
6. Have you or any company in which you were a director, executive officer, trustee, or principal
shareholder been named in any complaint, pleading, judgment, order, or decree filed in any federal,
state, or municipal court lawsuit which cited violations or alleged violations of any federal or state
statute or regulation?
YES NO
7. Have you ever been a director, executive officer, trustee, or principal shareholder of any state or
federally chartered bank, trust company, savings institution, credit union, or other financial institution
which became insolvent or was placed under supervision or in receivership, rehabilitation, liquidation,
or conservatorship while you occupied any such position or within one year thereafter?
YES NO
8. Has the certificate of formation, incorporation, or authority or license to do business as any state or
federally chartered bank, trust company, savings institution, credit union, or other financial institution
of which you were a director or executive officer ever been suspended or revoked while you occupied
any such position or within one year thereafter?
YES NO
9. Have you ever been requested, advised, ordered, or told by any regulatory authority or government
agency to divest any stock ownership or other ownership interest you have in any bank, trust
company, savings institution, credit union, or other financial institution?
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YES NO
10. Have you ever been requested, advised, ordered, or told by any regulatory authority or government
agency to leave or resign as a director, executive officer, agent, employee, consultant, or
representative of any bank, trust company, savings institution, credit union, or other financial
institution?
YES NO
11. Are you or any company in which you are a director, executive officer, trustee, or principal shareholder
involved as a named party in any ongoing or pending legal or administrative hearing, proceeding, or
investigation?
YES NO
12. Have you or any company with which you are or were associated and in which you were listed as
organizer, director, executive officer, or a principal shareholder been involved in any charter or license
application, a depository institution holding company application, federal deposit insurance
application, merger application, notice of a change of control (as an acquirer or transferee), or notice
of change in director, executive officer, or similar position where the filing was denied, disapproved,
withdrawn, or otherwise returned without favorable action by a federal or state regulatory authority
or a self-regulatory organization?
YES NO
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I hereby certify under penalty of perjury that I am acting on my behalf, and that the foregoing statements
are true and correct.
Signature: ____________________________________________ Date: ______________________________
Full Name: ___________________________________________
STATE OF TEXAS
COUNTY OF __________________
Personally appeared before me the above named,
personally known to me, who, being duly sworn, deposes and says that he/she executed the above instrument
and that the statements and answers contained therein are true and correct.
________________________________________,
Subscribed and sworn to before me this ___________________________, ________. ________ day of
________________________________________
(Notary Public)
(Seal)
My Commission expires: ___________________
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