Employment History. List your occupation/employment for the past 5 years: (include periods of unemployment) Employer’s Name & Address From (Mo/Yr) To (Mo/Yr) Reason for Leaving Unemployment (City & State) From (Mo/Yr) To (Mo/Yr) Training/Industry Designations Ethics: please describe your ethics training in the last five (5) years: Please list any Professional or Industry Designations you currently hold or Professional Organizations of which you are a member: NOTICE TO AGENT: We must advise you that American Fidelity Assurance Company (AFA) strictly adheres to the Federal Violent Crime Control and Law Enforcement Act and the IMSA Principles. As part of our normal appointment procedure, an investigative consumer report and/or a home office report may be prepared on you. This report contains information obtained via personal interviews with your neighbors, friends, or others with whom you are acquainted. These inquiries usually concern information on your character, general reputation, personal characteristics, criminal background (if any) and mode of living. Upon your written request, we can provide you with additional information as to the nature and scope of the report. By signing this application, you are representing that all the information recorded above is true and correct to the best of your knowledge. Further, you are authorizing AFA to do any background investigation or prepare any report we deem necessary to allow you to represent AFA. If you misrepresent any material fact recorded above, it will be cause for refusal or revocation of the right to represent AFA and possible notification to any state regulatory authority. Signature of Agent Date CHECKLIST: (Items listed below MUST be submitted to properly process your appointment.) ❐ ✍ Appointment Fee ❐ ✍ Two (2) Signed Agreements (if applicable) ❐ ✍ Copy of Your License ❐ ✍ Two (2) Commission Schedules (if applicable) ❐ ✍ Copy of Agency License (If commissions are to be paid to ❐ ✍ Signed Authorization for background investigation - M-2072 (FCRA3) Agency or Corporation.) ❐ ✍ Mail to: PO Box 25360, Oklahoma City, OK 73125 OR ❐ ✍ Copy of your E & O Schedule of Benefits page Fax to 000-000-0000 BD-1027 (APN) Revised 09/06 Sub-Producer Agreement THIS SUB-PRODUCER AGREEMENT is made and entered into on this day of , by and between AMERICAN FIDELITY ASSURANCE COMPANY, an Oklahoma corporation (hereinafter referred to as the "Company"), and an individual, partnership, limited liability company, or corporation (hereinafter referred to as "Sub-Producer"). (Please Print)
Appears in 3 contracts
Samples: Sub Producer Agreement, Sub Producer Agreement, Sub Producer Agreement
Employment History. List your occupation/employment LAST FIVE YEARS. YEAR CITY, STATE , AGENCY, TITLE, ROLE , , CURRENT TITLE EMPLOYMENT: START DATE END DATE PHONE NUMBER (WITH AREA CODE) Check all that apply: I am a licensed xxxxxx parent in the State of Washington, licensed with (agency name): I am an unlicensed relative / suitable other caregiver. I am a contracted provider in the State of Washington. I believe there is information about me, my business, or my family in FamLink. Please list below: NAME RELATIONSHIP WHAT TYPE OF RECORDS EXIST? By my signature below, I certify the following: The identifying information listed above is accurate and complete. I understand that this information will be used to conduct a search of FamLink records. I understand DCYF may deny or revoke access for any reason. I understand that I will be informed of the past 5 yearsdenial or revocation. I will not access FamLink data for any personal purpose. I understand my use of FamLink will be monitored by DCYF. I understand that in accordance to DCYF Information and Technology Security Policy 15.10, I shall not disclose my confidential passwords and access codes used to gain access to these systems. I also understand that if any of these codes or passwords is compromised, they will be changed immediately. The policies and procedures for information confidentiality have been explained to me and agree to follow all requirements. I agree to keep all information contained in these systems confidential. I will immediately report a breach or suspected breach of FamLink data to xxxx.xxxxxxxxxxx@xxxx.xx.xxx and any applicable DCYF program manager. EMPLOYEE / USER’S SIGNATURE DATE SUPERVISOR’S SIGNATURE DATE PRINTED NAME PRINTED NAME DCYF Use ONLY COMPLETION DATE BY WHOM RESULTS Verify Data Access Agreement Individual / Provider FamLink Record Check Completion Family Record Check Completed All required records restrictions completed and documented in FamLink FamLink Person ID: (include periods FamLink Provider ID: I certify that all terms of unemployment) Employerthe FamLink On-line Data Access Agreement have been and will continue to be met in regard to the above named individual’s Name & Address From (Mo/Yr) To (Mo/Yr) access to FamLink data. Please check the following action to be taken regarding the individual named below: Grant On-line FamLink Data Access Deny Access. Reason for Leaving Unemployment (City & State) From (Mo/Yr) To (Mo/Yr) Training/Industry Designations Ethicsdenial: please describe your ethics training in the last five (5) years: Please list any Professional or Industry Designations you currently hold or Professional Organizations Revoke Security and Eliminate FamLink Data Access DCYF ADMINISTRATOR / SPONSOR’S SIGNATURE DATE PRINTED NAME FAMLINK DATA ACCESS REQUEST / CHANGE Page 2 of which you are a member: NOTICE TO AGENT: We must advise you that American Fidelity Assurance Company (AFA) strictly adheres to the Federal Violent Crime Control and Law Enforcement Act and the IMSA Principles. As part of our normal appointment procedure, an investigative consumer report and/or a home office report may be prepared on you. This report contains information obtained via personal interviews with your neighbors, friends, or others with whom you are acquainted. These inquiries usually concern information on your character, general reputation, personal characteristics, criminal background (if any) and mode of living. Upon your written request, we can provide you with additional information as to the nature and scope of the report. By signing this application, you are representing that all the information recorded above is true and correct to the best of your knowledge. Further, you are authorizing AFA to do any background investigation or prepare any report we deem necessary to allow you to represent AFA. If you misrepresent any material fact recorded above, it will be cause for refusal or revocation of the right to represent AFA and possible notification to any state regulatory authority. Signature of Agent Date CHECKLIST: (Items listed below MUST be submitted to properly process your appointment.) ❐ ✍ Appointment Fee ❐ ✍ Two (2) Signed Agreements (if applicable) ❐ ✍ Copy of Your License ❐ ✍ Two (2) Commission Schedules (if applicable) ❐ ✍ Copy of Agency License (If commissions are to be paid to ❐ ✍ Signed Authorization for background investigation - M-2072 (FCRA3) Agency or Corporation.) ❐ ✍ Mail to: PO Box 25360, Oklahoma City, OK 73125 OR ❐ ✍ Copy of your E & O Schedule of Benefits page Fax to 000-000-0000 BD-1027 (APN) Revised 09/06 Sub-Producer Agreement THIS SUB-PRODUCER AGREEMENT is made and entered into on this day of , by and between AMERICAN FIDELITY ASSURANCE COMPANY, an Oklahoma corporation (hereinafter referred to as the "Company"), and an individual, partnership, limited liability company, or corporation (hereinafter referred to as "Sub-Producer"). (Please Print)
Appears in 1 contract
Samples: www.dcyf.wa.gov
