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Applicant Name (Company) NAIC No. ___________ FEIN: BIOGRAPHICAL AFFIDAVIT
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Document Date: 2012-01-19 14:52:22

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Country

United States / /

Facility

University City/ State Dates Attended / /

IndustryTerm

banking / duplication services / insurance regulatory authority / Business telephone / non-management services / state law / insurance reviewing / non-insurance regulatory issuer / /

Organization

Federal Government / known_______________________________________________ Organization / state insurance regulatory authority / /

Position

administrator / manager / operator / / Supervisor / officer / member of the board of directors / officer / management representative / Comptroller / director / trustee / /

ProvinceOrState

Oklahoma / Minnesota / California / /

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