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