Florida Department of Financial Services
Bureau of Licensing
AALF Application
Social Security Number: License Number: Date of Birth: Application ID Number:
XXX-XX-XXXX W255919 08/04/1995 4815656

Name: Accepted Date:
BATES, FOREST DUAYNE 04/23/2015

Home Address Business Address
5376 NW 79TH WAY
PARKLAND, FL 33067
(503) 407-4658 		5376 NW 79TH WAY
PARKLAND, FL 33067
(503) 407-4658

Mailing Address
5376 NW 79TH WAY
PARKLAND, FL 33067

Email Address
DRAGONBALL.COLLECTOR@YAHOO.COM
Applied For:
02-14 - Resident Life Including Variable Annuity Insurance Agent
NOTE: ALL FEES ARE NON-REFUNDABLE.
Fees:
Application Fee 50.00
License Fee 5.00
Processing Fee 2.45

Total Fees Paid: 57.45

Credit Card Confirmation: 240379725
Screening Questions:

Are you applying for a license for the PRIMARY purpose of writing insurance covering a debtor of a firm, association, or corporation in which you are an officer, director, stockholder, partner or employee?
Yes/No No


Are you applying for a license for the PRIMARY purpose of placing insurance on your own life, interests or that of members of your family?
Yes/No No


Are you applying for a license in order to place insurance PRINCIPALLY on an officer, director, stockholder, partner or employee of a business in which you or a member of your family is engaged?
Yes/No No


Are you an employee of the United States Veterans Administration or its State Service Office?
Yes/No No


Are you a funeral director, direct disposer or an employee or representative thereof, or do you have an office in or in connection with a funeral establishment?
Yes/No No


In the last three years, have you held a resident license in any state for the same lines of insurance, and was that license valid for a minimum of one year?
Yes/No No


Within the last four years, I have taught or completed a 40 hour pre-licensing course that was approved by the Florida Department of Financial Services for this license type.
Yes/No Yes


Identify the following:
Completion Date of Course: 04/05/2015


Identify the following:
Name of Pre-License Classroom Course: examfx


Do you have the Chartered Life Underwriter (CLU) designation?
Yes/No No


Are you a United States Citizen?
Yes/No Yes


If you have held a license in another state in prior years, you may be exempt from the exam. Have you held a license in another state for a minimum of one (1) year immediately preceding the date you became a resident of this state and have not been a resident of Florida for more than 90 days from today's date.
Yes/No No


Are you currently on probation for any legal action or participating in a pretrial intervention program or any other diversion program?
Yes/No No


Are there currently pending against you or any entity you control, any criminal, administrative (including those by FINRA) or civil charges in any state or federal court anywhere in the United States or its possessions or any other country?
Yes/No No


In the past 12 months, have you been arrested, indicted, or had an Information filed against you or been otherwise charged with a crime by any law enforcement authority anywhere in the United States or its possessions or any other country?
Yes/No No


Have you ever been convicted, found guilty, or pled guilty or nolo contendere (no contest) to a felony under the laws of any municipality, county, state, territory or country, whether or not adjudication was withheld or a judgment of conviction was entered, and whether or not the records are sealed or expunged?
Yes/No No


Has a judgment ever been obtained or is there currently pending any type of civil action as it relates to insurance against you individually or against any entity in which you are or were an officer, director, partner, or owner?
Yes/No No


Has any insurance agency that you are now or have you ever been, an officer, partner, joint venturer, shareholder, or owner, filed for protection under the Bankruptcy Act or been the subject of a petition for involuntary bankruptcy? (This does not include personal bankruptcy.)
Yes/No No


Has any company ever refused to bond you?
Yes/No No


Have you ever been refused a securities, real estate broker, or other license by a state agency or a public authority in any jurisdiction?
Yes/No No


Have you ever had an application for a license declined or denied by this or any other insurance regulatory body (including FINRA)?
Yes/No No


Have you ever had any professional license subjected to any of the following actions by any state agency or public authority or any other regulatory authority (including FINRA) in any jurisdiction:
  • Revocation of an insurance license in Florida less than two years ago
  • Revocation in another state at any time or in Florida more than two years ago
  • Suspension
  • Placed on probation
  • Administrative fine or penalty levied
  • Cease and desist order entered
  • Revocation of a non-insurance license in Florida less than two years ago
Yes/No No


Have you ever had any insurance agency contract terminated by an insurance company or managing general agent for any alleged cause?
Yes/No No


Are you currently indebted to any insurer, managing general agent, agent, or premium finance company?
Yes/No No


I affirm that I understand I must maintain a valid email address on file with the Department.
Yes/No Yes


Have you failed to comply with any civil, criminal, or administrative action taken by a child support enforcement program under Title IV-D of the Social Security Act, 42 U.S.C. ss. 651 et seq., to determine paternity or to establish, modify, enforce, or collect support?
Yes/No No

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Applicant Affirmation Statement
Where required by law, I hereby name and appoint the Chief Financial Officer of the State of Florida my attorney to receive service of legal process issued against me, upon causes of action arising within the State of Florida out of transactions under my Florida license; that this appointment shall constitute effective legal service upon me as long as there may be any cause of action against me arising out of insurance transactions within the State of Florida. (Sections 626.741; 626.742; 626.792; 626.835; 626.836; 626.84201, F.S.)

Whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his/her official duty shall be guilty of a misdemeanor of the second degree provided under section 837.06, F.S.

I have read the foregoing application and the facts stated in it are true to the best of my knowledge and belief. I have not withheld any information that would in any way affect my qualifications. I understand that misrepresentation of any fact required to be disclosed through this application may result in the denial of my application and the revocation of my insurance license(s).

I understand that as an applicant who is subject to a national fingerprint-based criminal history record check, I have certain rights based on Title 28, Code of Federal Regulations (CFR), Section 16.30-16.34. The rights include a reasonable time to respond to the agency for any deficiencies reported in the criminal history report; the ability to challenge the accuracy of the information in the report by contacting the FBI; and any records held by the agency will be used and retained according to the FBI Criminal Justice Information Services (CJIS) requirements. A copy of the a Noncriminal Justice Applicants Privacy Rights may be obtained by visiting our website at https://myfloridacfo.com/division/agents/licensing/agents-and-adjusters/fingerprinting-information.

I understand that, per section 626.171(5), F.S., all application fees are non-refundable.

XI agree to the above statement.
Affirmation Name(s):
Forest Bates 04/23/2015
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