Form 41429 - Application For Agent'S Renewal Permit - State Of Indiana
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1OFFICE USE ONLY
APPLICATION FOR AGENT'S RENEWAL PERMIT
Fee paid
Check receipt number
State Form 41429 (R5 / 9-99)
$
Approved by State Board of Accounts 1988
Card number
INDIANA COMMISSION ON PROPRIETARY EDUCATION
NOTE:
This form must be completed for each agent representing an institution.
Approval date:
If all of the information which is required on this form is not provided, the form
From
To
will be returned to the institution.
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?
Yes
No
(a) If you answered yes, state reason(s):
5. Have you been convicted of a felony within the last year?
Yes
No
(a) If you answered yes, give details in full:
6. Have you been convicted of a crime involving moral turpitude within the last year?
Yes
No
(a) If you answered yes, give details in full:
AFFIDAVIT
I hereby swear or affirm that the above statements are true.
Signature of applicant
}
STATE OF
SS:
COUNTY OF
Subscribed and sworn to before me this ___________________________ day of _____________________________________________ , ________ .
Signature of Notary
Printed name of Notary
My Commission expires:
County of residence:
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