New York State Department / County Clerk’s Office / ORIGINAL/RELICENSING ENTITY FORM NEW YORK STATE DEPARTMENT OF FINANCIAL SERVICES Attention / New York State Department of State / Licensing Services Bureau / Department of Taxation and Finance / U.S. Securities and Exchange Commission / Division of Corporations / FINRA / Department of Financial Services / Department of Taxation / US Federal Reserve / National Association of Insurance Commissioners / NASD / /
Person
Alberta Manitoba / Edward Isl / Virginia Washington West Virginia / Make Check Payable / Montana Nebraska Nevada / / /
Position
driver / Sub-licensee/Designated Responsible Officer/Director / Officer /Director Signature / Officer /Director City Title / Commissioner / Director / manager / officer /director / Officer /Director P. O. Box / County Clerk / PRODUCER / Officer / Superintendent / owner/officer/director/partner/member/ manager / owner/officer/director/partner/member/manager / Officer /Director Social Security No* Date / Officer /Director URL WebSite / licensed insurance producer / National Producer / Governor / HEALTH BROKER / Director / appropriate representative / Director / or Superintendent / National Insurance Producer / judge / securities salesman / Prince / /
ProvinceOrState
Alaska / Louisiana / Hawaii / New York / District of Columbia / Iowa / Arizona / Idaho / Arkansas / Ontario / /
Producer Application and Instructions for Life Agent’s License (Entity)