Application For Certificate Of Authority (Motor Club) Page 10
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15Other Training: Name
City/ State
Dates Attended (MM/YY)
Degree/Certification Obtained
(Note: If affiant attended a foreign school, please provide full address and telephone number of the
college/university. If applicable, provide the foreign student Identification Number in the space
provided in the Biographical Affidavit Supplemental Information.)
7.
List of memberships in professional societies and associations.
Name of
Address of
Telephone Number
Society/Association
Contact Name
Society/Association
of Society/Association
8.
Present or proposed position with the applicant entity. _________________________________________
____________________________________________________________________________________
9.
List complete employment record for the past ten (10) years, whether compensated or otherwise
(up to and including present jobs, positions, partnerships, owner of an entity, administrator,
manager, operator, directorates or officerships). Please list the most recent first. Attach additional
pages if the space provided is insufficient.
Beginning/Ending
Dates (MM/YY) ________ - ________ Employer’s Name ____________________________________________
Address ________________________ City _____________________ State/Province ___________________
Country ____________ Postal Code ________ Phone _________ Offices/Positions Held ________________
Supervisor / Contact __ _______________________________________________________________________
Beginning/Ending
Dates (MM/YY) ________ - ________ Employer’s Name ____________________________________________
Address ________________________ City _____________________ State/Province ___________________
Country ____________ Postal Code ________ Phone _________ Offices/Positions Held _________________
Supervisor / Contact __ _______________________________________________________________________
Beginning/Ending
Dates (MM/YY) ________ - ________ Employer’s Name ____________________________________________
Address ________________________ City _____________________ State/Province ____________________
Country ____________ Postal Code ________ Phone __________ Offices/Positions Held _________________
Supervisor / Contact __ _______________________________________________________________________
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