Local Agent for Licensed Properties

2. 
4. Property Information*
   Address of Property
6. City*
7. State*
   -- Select One --AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPeurto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming
8. Zip Code*
10. Name of Legal Property Owner(s)*
    Owner's First & Last Name
12. Agent Information*
    Agent's First & Last Name
14. Agent's Address*
    P.O. Box Not Acceptable
16. Phone Number*
17. Fax Number
18. Email Address*
22. I, the undersigned, hereby certify that:*

    By checking the "I agree" box below, I/we authorize my/our aforementioned agent to act on my/our behalf as my/our registered agent, and assume all of the duties listed above. However, I/we understand that as the legal owner(s) of this property I/we will be responsible for the actions/and or infractions of the agent listed above.

    1. I agree
24. Owner's Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
26. Owner's Electronic Signature*
27. Owner's Email Address*
28. Date*
    Date
30. Agent's Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
32. Agent's Electronic Signature*
33. Agent's Email Address*
34. Date*
    Date
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field