Free 20561.PDF - Indiana

NOTIFICATION OF AGENT TERMINATION
State Form 20561 (R3 / 9-99)

INDIANA COMMISSION ON PROPRIETARY EDUCATION

Fill out the information listed below when an agent(s) is no longer employed at your institution:
Name of institution

Location of institution (number and street, city, state, ZIP code)

NAME OF AGENT

DATE OF TERMINATION

AGENT PERMIT CARD ENCLOSED

If the Agent Permit Card(s) cannot be returned for ___________________________________________________________________________________ _________________________________ , provide below a notarized statement certifying this: WE ARE UNABLE TO RETURN THE AGENT PERMIT CARD(S) FOR THE FOLLOWING REASON:

Signature

Printed name

Official Capacity

SUBSCRIBED AND SWORN TO ME THIS _______________ DAY OF ____________________________________________________, _________ .
My Commission expires: Signature of Notary

County of residence

Printed name of Notary