Free 41429.PDF - Indiana

APPLICATION FOR AGENT'S RENEWAL PERMIT
State Form 41429 (R5 / 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 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. Please list other institutions you have represented in the past year.

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

Yes

No

5. Have you been convicted of a felony within the last year? (a) If you answered yes, give details in full:

Yes

No

6. Have you been convicted of a crime involving moral turpitude within the last year? (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: