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SECURITIES AND BUSINESS REGULATION 2 Martin Luther King, Jr. Drive, S.E. Ste 802, West Tower Atlanta, Georgia 30334 (404) 656-3079 http://www.sos.state.ga.us/securities/ ROBERT D. TERRY Director CATHY COX Secretary of State Application For Registration As A Preneed Salesperson Pursuant To The Georgia Cemetery and Funeral Services Act of 2000 Application Fee $100.00 Part I - Employer Name of Preneed Dealer or Cemetery Registration Number Mailing Address (Number and Street) City State Zip Code Office of Employment Address (Number and Street) City State Zip Code Person to Contact Regarding This application Phone Number Part II - Applicant Name (Last) (First) (Full Middle or Maiden Name - specify if none) Address (Number and Street) City Date of Birth Social Security Number State Zip Code Telephone Number Part III – Background Information 1. 2. 3. Do you have any type of working relationship with any other cemetery, preneed dealer or insurance company? If yes, explain Have you ever engaged in any unethical or dishonest practices in the funeral or cemetery business? If yes, explain Have you been permanently or temporarily enjoined, suspended, or barred by any court of competent jurisdiction or by any state or other jurisdiction from engaging in or continuing any conduct or practice involving any aspect of the funeral or cemetery business? If yes, explain Part IV - Applicant's Certification I certify that I have read, understand, and agree to abide by, comply with, and adhere to all of the provisions, conditions and covenants of the Georgia Cemetery and Funeral Services Act of 2000, and the Rules and Regulations promulgated thereunder. I hereby certify that I am at least 18 years of age; that I am not subject to any order of the Secretary of State that restricts my ability to be registered as a preneed sales agent; and I have not been adjudicated, civilly or criminally, have not committed fraud or violated any law of any state involving fair trade or business practices, have not been convicted of a misdemeanor of which fraud is an essential element or which involves any aspect of the funeral or cemetery business nor have I been convicted of a felony. By signing this application, I give authorization to the Office of Secretary of State to conduct a criminal history background on myself. This ___________day of ___________________, 200________ _________________________________________________________ _ (Signature of Applicant) _________________________________________________________ _ (Notary Public) My Commission expires: _______________________________________ Part V - Employer Certification I hereby certify that the applicant is authorized to offer, sell, and sign preneed contracts on behalf of the cemetery or preneed dealer listed in Part 1 of this application, and that the applicant has been informed of the requirements and prohibitions of the Georgia Cemetery and Funeral Services Act of 2000 relating to preneed sales. I further certify that the applicant has been informed of the cemetery or preneed dealer’s preneed contract, and the nature of the merchandise, services or burial rights sold by the cemetery or preneed dealer. C-2 Rev 5/2000 ________________________________________________ Authorized Signature and Title C-2 Rev 5/2000