Free OFFICE OF THE SECRETARY OF STATE - Texas

Form 2604--General Information (Automobile Club Agent Application/Renewal)
The attached form is designed to meet minimal statutory filing requirements pursuant to the relevant code provisions. This form and the information provided are not substitutes for the advice and services of an attorney.

Commentary Automobile Clubs are governed by Chapter 722 of the Texas Transportation Code (the "Automobile Club Services Act") and the secretary of state's administrative rules found in 1 Texas Administrative Code Chapter 75. An Automobile Club Agent Application must be filed no later than the 30th day after the date the automobile club employs the agent. Applications expire twelve months from the date of issuance and must be renewed. This form must be used for renewal applications as well as new applications. Instructions for Form · Preliminary Information: Select the appropriate box indicating whether this is a new application or an application for renewal. If it is a renewal, you should provide the registration number assigned by the secretary of state to facilitate processing of the document. Agent Information: Include the automobile club name and the full legal name, date of birth, address, social security number and gender of the agent. The secretary of state will redact the social security number prior to providing a copy of this form in response to a public information request. A document on file with the secretary of state is a public record subject to public access and disclosure. When providing address information, use a business or post office box address rather than a residence address if privacy concerns are an issue. · Information Pertaining to Agent's Moral Character: If the agent has never been convicted of a felony or misdemeanor, select "no," and proceed to the execution portion of the application. If the agent has been convicted of a felony or misdemeanor, state the nature of the offense, the final disposition, and explain the circumstances surrounding the offense. Also attach copies of the court order or final conviction and sentence and any papers pertaining to release from probation. Submission of this form is consent to conduct a criminal history search of the agent. · · Execution: Both the agent and an authorized representative for the automobile club must sign the form. Payment and Delivery Instructions: The filing fee for an Automobile Club Agent Application is $10. Fees may be paid by personal checks, money orders, LegalEase debit cards or MasterCard, Visa, and Discover credit cards. Checks or money orders must be payable through a U.S. bank or financial institution and made payable to the secretary of state. Fees paid by credit card are subject to a statutorily authorized convenience fee of 2.7 percent of the total fees. The form, along with the filing fee, may be mailed to P.O. Box 13550, Austin, Texas 787113550 or delivered to the James Earl Rudder Office Building, 1019 Brazos, Austin, Texas 78701. The secretary of state will issue a certificate of authority upon filing of a completed application.
Revised 03/09

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Form 2604

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Form #2604

Rev. 03/2009

This space reserved for office use

Submit to: SECRETARY OF STATE Statutory Documents Section P O Box 13550 Austin, TX 78711-3550 512-475-1769 512-475-2815 - Fax Filing Fee: $10

AUTOMOBILE CLUB AGENT APPLICATION / RENEWAL

New Application Renewal Application Registration Number:

Automobile Club Information
Name:

Agent Information
Name: Address:
Street City State Zip

Date of Birth:

Social Security Number:

-

-

Gender:

Male

Female

Information Pertaining to Agent's Moral Character
Has Agent ever been convicted of a felony or misdemeanor? Yes No If YES, A. Attach a copy of the court order or final conviction and sentence. Also attach a copy of any papers pertaining to release from probation. B. State the nature and disposition and explain the circumstances of the offense(s):
Use and attach an additional sheet if necessary

Execution
Date:
Signature of AGENT Printed or typed name of AGENT

Date:
Signature of authorized person FOR AUTOMOBILE CLUB Printed or typed name of authorized person FOR AUTOMOBILE CLUB

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Form 2604

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