Agent Prequalification Form – Fill Out and Use This PDF

AGENT PRE-QUALIFICATION FORM

1‐ What is the Name of your Business?

	________________________________________________________________
2‐	Business Address?
	________________________________________________________________
	City:_______________________ State:____________		Zip Code:_________
	Telephones: ________________________________ Fax:__________________
	Email Address: ___________________________________________________
3‐	Has your business been Incorporated (INC)?	Yes___	No___

4‐ What is the Name appearing on your Incorporation License?

_______________________________________________________________

Please provide proof (copy of License)

Services provided?

___________________________________________________

5‐ Business Federal Employer Identification Number (FEIN) or Tax Id. Number?

_______________________________________________________________

Please provide proof (copy of License)

6‐ Social Security Number(s) of the major partners?

1.Last Name:______________________First Name:____________________

Alien Card #________________________Driver’s lic #_____________________

SSN___ ___ ___‐ ___ ___ ‐ ___ ___ ___ ___

RESIDENTIAL ADDRESS:_________________________________________________

Phone:_________________________Cell:__________________________

Rent:___________ Own:___________

2.Last Name:______________________First Name:____________________

Alien Card #_____________________Driver’s lic #________________________

SSN__ ___ ___ ‐ ___ ___ ‐ ___ ___ ___ ___

RESIDENTIAL ADDRESS:_________________________________________________

Revised August 2010

Internet Submission

Agent Pre-Qualification Form

Fax No. 1 (800) 866-3108

Phone:__________________________Cell:__________________________

Rent:___________ Own:___________

7‐ Is the name shown on your Incorporation license different from that under which you do business?

Yes____No____

8‐ Has the name under which you do business (make advertisement, flyers, radio spots, TV ad etc.) been registered as a DBA (Doing Business As)?

Yes:____No:____

If registered, please provide proof (copy of Registration).

9‐ Have you ever declared bankruptcy?Yes:____No:____

If Yes, Date:______________________

Please list the Business and Partner’s personal bank accounts:

1.‐ Bank:________________________ acc#_________________________________

2.‐ Bank:________________________ acc#_________________________________

3.‐ Bank:________________________ acc#_________________________________

REFERENCES: (2 NAMES)

1.‐ NAME:____________________________________PHONE__________________

ADDRESS:____________________________________________________________

2.‐ NAME:____________________________________PHONE__________________

ADDRESS:____________________________________________________________

NOTA BENE

The above information being asked of you is required by your State Financial Regulators. The undersigned acknowledge that the above is true and correct and hereby authorize Unitransfer to use any legal means to corroborate them. They understand this questionnaire will be used for credit inquiry and background check. If the application is approved, they hereby authorize Unitransfer to perform periodic credit and background checks.

If you have any questions, please contact the Management Department at 1‐877‐864‐8726.

Signature: (1)________________________________	Date:______________
Signature: (2)________________________________	Date:______________

This instrument has been signed before me on the ……. day of …………. 20…. By…………………....

………………………………….who presented …………………………………..as

identification or is personally known to me.

____________________________

Notary Name, Seal and Signature

Revised August 2010

Internet Submission

Agent Pre-Qualification Form

Fax No. 1 (800) 866-3108