Form Ndoi 212 - Nevada Division Of Insurance

Department of Business and Industry

Nevada Division of Insurance

1818 E. College Pkwy, Suite 103, Carson City, Nevada 89706 Phone: (775) 687-0700 Fax: (775) 687-0797 Web: doi.nv.gov

Fees: Adding lines of authority $50. Adding Agency Affiliation $50 per affiliation.

Fees are payable to the Nevada Division of Insurance

Please check the box(s) that apply:

Adding Lines of Authority

Adding an Agency Affiliation

Division Use Only: Fees: _________________ Check #: ___________Application ID#: ___________ IND ID#: ____________

: __

Approved by:__________ Date:_____________ License No: ____________________ NV Resident Criminal History Report

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Soc. Security Number

If applicable, NASD Individual Central Registration Depository (CRD) Number

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Are you affiliated with a financial institution/bank?

3

Yes

No

Last Name

JR./SR. etc

First Name

Middle Name

Date of Birth

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5

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(month) ____ (day) ____ (year)_____

Residence/Home Address (Physical Street)

P.O. Box

City

State

Zip or Foreign Country

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10

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12

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Home Phone Number

Gender (Circle One)

Are you a Citizen of the United States? (Check One)

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(

)

-

Male

Female

Yes

No

(If No, of which country are you a citizen?)

(If No, you must supply work authorization)

List your Nevada License Number (s):

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Business Address (Physical Street)

P.O. Box

City

State

Zip or Foreign Country

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Business Phone Number

Business Fax Number

Business E-Mail Address

Business Web Site Address

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(

)

-

(

)

-

Applicant’s Business Mailing Address

P.O. Box

City

State

Zip or Foreign Country

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Nonresidents: “Home State” where you hold a Resident License

If Applicable, beginning date of residency in the State of Nevada:

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_________Month

__________Day

__________Year

__________________________________________

Please mark the lines of authority you are adding:

Life____ Health____ Variable Annuity/Life____ Property____ Casualty____ Personal Lines____ Limited Credit____ Limited Fixed Annuities____

Residents of Nevada: You must attach the original pre-licensing education certificate and original Pearson VUE test results.

Non-residents must hold the same lines of authority in their home state.

The Division encourages the use of Sircon’s Compliance Express at for submitting and processing individual

affiliations or terminations. The process is instantaneous and eliminates the necessity of the paper filing.

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List your Current Insurance Agency Affiliations (if applicable):

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Fein # ____________________________ Name of Agency

NV License Number(s):

___________________________________________

Fein # ____________________________ Name of Agency

NV License Number(s):____

___________________________________________

List the Insurance Agency Affiliations you are adding:

Fein # ____________________________ Name of Agency

NV License Number(s):

___________________________________________

Fein # ____________________________ Name of Agency

NV License Number(s):____

___________________________________________

I hereby certify that, under penalty of perjury, all of the information submitted in this application and attachments is true and complete. I am aware that submitting false

information or omitting pertinent or material information in connection with this application is grounds for license revocation or denial of the license and may subject me

to civil or criminal penalties. I further certify that I grant permission to the Commissioner of Insurance to verify information with any federal, state or local government

agency, current or former employer, or insurance company. I authorize the Commissioner of Insurance to give any information concerning me, as permitted by law, to

any federal, state or municipal agency, or any other organization and I release the jurisdictions and any person acting on their behalf from any and all liability of

whatever nature by reason of furnishing such information.

___________________________________________________

Original Applicant Signature

(Date)

NDOI 212 Doc 327A Individual Modification Form (rev 6.30.2015)

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