Free 39286.PDF - Indiana

APPLICATION FOR AGENT'S PERMIT
State Form 39286 (R4 / 9-99) Approved by State Board of Accounts 1988 INDIANA COMMISSION ON PROPRIETARY EDUCATION

OFFICE USE ONLY
Fee paid Check receipt number

$
Card number

NOTE:

This form must be completed for each new agent representing an institution. If all of the information which is required on this form is not provided, the form will be returned to the institution.

Approval date:

From

To

1. Name and location of institution(s) to be represented on permit:

2. Name of applicant

Address (number and street) State ZIP code

City

Telephone number

3. Have you ever been employed as an agent for any public or private institution?

Yes

No

(a) If you answered yes, please list all former institutions. State period of time employed with each institution listed.

4. Have you ever been denied a license to represent an institution in any state? (a) If you answered yes, state reason(s):

Yes

No

5. REFERENCES:

LIST THREE CHARACTER REFERENCES NOT RELATED TO YOU. (Include their names, addresses and telephone numbers)

6. Birthdate

Birthplace

U.S. Citizen?

Date of naturalization

Yes
7. Have you ever been convicted of a felony? (a) If you answered yes, give details in full:

No

Yes

No

8. Have you ever been convicted of a crime involving moral turpitude? (a) If you answered yes, give details in full:

Yes

No

AFFIDAVIT I hereby swear or affirm that the above statements are true.
Signature of applicant

STATE OF COUNTY OF

}

SS:

Subscribed and sworn to before me this ___________________________ day of _____________________________________________ , ________ .
Signature of Notary Printed name of Notary

My Commission expires:

County of residence: