Application For Certificate Of Authority (Motor Club) Page 9

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UTAH STATE MOTOR CLUB
BIOGRAPHICAL AFFIDAVIT
To the extent permitted by law, this affidavit will be kept confidential by the state insurance regulatory authority.
IF THE ANSWER TO ANY QUESTION IS “NO” OR “NONE”, PLEASE SO STATE.
(Print or Type)
Full Name, Address and telephone number of the present or proposed entity under which this biographical
statement is being required (Do Not Use Group Names).
In connection with the above-named entity, I herewith make representations and supply information about
myself as hereinafter set forth. (Attach addendum or separate sheet if space hereon is insufficient to answer
any question fully.)
1.
a. Affiant’s Full Name (Initials Not Acceptable).
b. Maiden Name (if applicable).
2.
a. Have you ever had your name changed? __ If yes, give the reason for the change and provide
the full name(s).
b.
Other na
3.
a. Are you a citizen of the United States?
b. Are you a citizen of any other country, if so, what country?
4.
Affiant’s Occupation or Profession.
5.
Affiant’s business address.
Business telephone.
6.
Education and Training:
College/ University
City/ State
Dates Attended (MM/YY)
Degree
Obtained
__________________________________________________________________________________________
Graduate Studies:
College/ University
City/ State
Dates Attended (MM/YY)
Degree Obtained

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