Fill and Sign the Marshall Ffa Scholarship Application Form

Print Form NEW JERSEY APPLICATION FOR AUTHORIZATION AS AN INDEPENDENT CERTIFIED PUBLIC ACCOUNTANT FOR CAPTIVE INSURANCE BUSINESS INDIVIDUAL PARTNERSHIP CORPORATION OTHER IF APPLICANT IS A COMPANY, FILL IN NAME HERE, THEN CONTINUE ON THE NEXT PAGE IF APPLICANT IS AN INDIVIDUAL: 1. Full Legal Name 2. Residence Address 3. (A) Office Phone Number (b) Email Address 4. Education and Degree High School College Graduate or Professional 5. List all insurance and/or captive auditing experience for the past 15 years including specific dates (attach additional sheets if necessary.) 6. List the captive account(s) you will be auditing. 7. Present Chief Occupation Position or Title Employer’s Name Address How long with this employer? How long in this position? 8. Has applicant ever been arrested, or indicted for and/or convicted of any crime or offense other than a traffic violation? If “yes”, please submit full particulars of each case and disposition thereof. Yes No 9. I control directly or indirectly, or own legally or beneficially, the outstanding stock of the following insurers: 10. Do you currently hold or have you held any type of insurance license? (Type) (State) (Expiration Date) 11. Have you ever had a license or privilege refused or revoked by an Insurance Department? If so, give details. 12. Are you currently licensed as a CPA? If so, please indicate state. 13. Has your license as a CPA in this state or any state ever been suspended or revoked? attach details. IF APPLICANT IS OTHER THAN AN INDIVIDUAL: 14. Name of Firm: 15. Business address: Federal ID No: Telephone No: 16. Names of Partners responsible for Captive Audits: 17. Indicate insurance experience of partner, manager, supervisor, or individual(s) responsible for auditing of captive (attach additional sheets if needed): If so, 18. Will you assign only individuals that have a minimum of two years insurance auditing experience? Yes *19. No The Department may publish my contact information on its website. Yes No ***Please include BIOGRAPHY AFFIDAVIT(S) for Individual or Individuals responsible for Audits*** I hereby certify that I have read and understand all of the requirements and provisions of the Captive Insurance Company Regulations, and will fully comply therewith. Signed Subscribed and sworn to before me this Dated day of 20 Signature of Notary Public Notary Public authorized by law of the State of to administer oaths. My commission expires on: NOTARY SEAL Note: Unless otherwise indicated, once approved, your contact information will be published on the Department’s Captive Insurance Website. DHT11-03 Appendix A Exhibit 5/inoregs