Pre-Need Establishment Registration Form - Mississippi Secretary Of State (Page 5 of 5) in pdf

Pre-Need Establishment Registration Form - Mississippi Secretary Of State Page 5

MISSISSIPPI SECRETARY OF STATE

PRE-NEED AGENT

REGISTRATION FORM

Eric Clark, Secretary of State

MS Registration A - ______________

Initial Registration

Amendments

(Changes in this information are required to be provided to the Secretary of State's Office within 30 days of when

the change occurs.)

PLEASE TYPE OR PRINT IN BLACK INK.

1. Agent Name ____________________________________________________________________________

2. Mailing Address _________________________________________________________________________

City _________________________________ State ______________________ Zip Code ______________

3. Physical Address (if different) ______________________________________________________________

City ________________________________ State _______________________ Zip Code ______________

4. Telephone number(s) _____________________________________________________________________

5. Fax number __________________________________ 6. E-mail __________________________________

6. List all funeral establishments, including addresses and phone numbers, through which you will be selling.

__________________________________________________________________________________________

I certify that all information provided is true and correct to the best of my knowledge.

________________________________________________

Signature of Applicant

Date

Name (PRINT)

________________________________________________

Title (PRINT)

(This form should be mailed to Mississippi Secretary of State’s Office, Pre-Need Registration, P.O. Box 136,

Jackson, MS 39205-0136.)

Page 1 of 1

Rev. 5/2004

Pre-Need Establishment Registration Form - Mississippi Secretary Of State Page 5