T2637 Appendix 1 Pre Register 2.18.20.docx

Appendix 1

T2637 INSURANCE AND REAL ESTATE LICENSE EXAMINATIONS AND

SELECTED SERVICES, DOBI 20DPP00498

CANDIDATE PRE-REGISTRATION FORM

1. Have you ever been convicted of, or are you currently charged with, committing a crime, whether or not adjudication was withheld? Yes ___ No___ “Crime” includes a misdemeanor, felony or a military offense. You may exclude misdemeanor traffic citations and juvenile offenses. “Convicted” includes, but is not limited to, having been found guilty by verdict of a judge or jury, having entered a plea of guilty or nolo contendre, or having been given probation, a suspended sentence or a fine.

2. Have you or any business in which you are or were an owner, partner, officer or director ever been involved in an administrative proceeding regarding any professional or occupational license? Yes ___ No___ “Involved” means having a license censured, suspended, revoked, canceled, terminated; or, being assessed a fine, placed on probation or surrendering a license to resolve an administrative action. “Involved” also means being named as a party to an administrative or arbitration proceeding which is related to a professional or occupational license. “Involved” also means having a license application denied or the act of withdrawing an application to avoid a denial. You may exclude terminations due solely to noncompliance with continuing education requirements or failure to pay a renewal fee.

3. Has any demand been made or judgment rendered against you for overdue monies by an insurer, insured or producer, or have you ever been subject to a bankruptcy proceeding? Yes ___ No___

4. Have you been notified by any jurisdiction to which you are applying of any delinquent tax obligation that is not the subject of a repayment agreement? Yes ___ No___

5. Are you currently a party to, or have you ever been found liable in, any lawsuit or arbitration proceeding involving allegations of fraud, misappropriation or conversion of funds, misrepresentation or breach of fiduciary duty? Yes ___ No___

6.Have you ever received any civil penalty or fine, or been required to provide restitution to any person, pursuant to any unfair trade practice statute, consumer fraud or consumer protection statute; insurance fraud statute or similar statute in this State, any other state or by the federal government; or are any such complaints presently pending against you? Yes ___ No ___

7. Do you have a child support obligation in arrearage by six months are more? Yes ___ No___

If you answer yes to Question 7, by how many months are you in arrearage? ___________ Months

8. Are you the subject of a child support related subpoena or warrant? Yes ___ No___