By affixing my name to this application I,
hereby certify, (i) that I am an
authorized agent of the applicant described and identified in this application for
renewal licensure of agent, (ii)that I am the person who submitted the answers to
each of the questions listed in this applicaton, and (iii) that the information
I have provided in connection with the submission of this application is truthful,
correct, complete and free of fraud, misrepresentation, or omission of material
I will ensure that any information subsequently submitted to the Idaho Department
of Finance in conjunction with this application or its supporting documents meet
the same standard as set forth above.
By affixing my name, date of birth, and mother's maiden name, and submitting this
application electronically, I understand that I am as fully responsible for the
contents herein as though I had signed and submitted this application manually.