NATION SAFE DRIVERS Texas COVER SHEET AUTOMOBILE CLUB REPRESENTATIVE APPOINTMENT PROCEDURE  Complete the Automobile Club Agent Application –legibly print or type all information  All producers must complete the Background Inquiry Authorization  $10 Licensing fee  $20 Background inquiry fee for all producers Make Checks payable to Nation Safe Drivers and mail both the check and all completed forms to: Nation Safe Drivers Licensing & Compliance Department 800 Yamato Road, Suite 100 Boca Raton, Florida 33431 Feel free to contact us with any questions: 800-338-2680 ext. 516 [email protected] Revised 4/23/2012 Form #2604 Rev. 02/2012 Submit to: SECRETARY OF STATE Registrations Unit P O Box 13550 Austin, TX 78711-3550 512-475-1769 512-475-2815 - Fax This space reserved for office use AUTOMOBILE CLUB AGENT APPLICATION / RENEWAL New Application Registration Number: Renewal Application Automobile Club Information Name: Nation Motor Club, Inc. Assumed Name: Nation Safe Drivers Agent Information Name: Date of Birth: Address: Street City Social Security Number: - - State Gender: Zip Male Female Yes No Information Pertaining to Agent’s Moral Character Has Agent ever been convicted of a felony or misdemeanor? If YES, A. Attach a copy of the court order or final conviction and sentence. Also attach a copy of any papers pertaining to release from probation. B. State the nature and disposition and explain the circumstances of the offense(s): Use and attach an additional sheet if necessary Execution Date: Signature of AGENT Printed or typed name of AGENT Date: Signature of authorized person FOR AUTOMOBILE CLUB Andrew M. Smith - President Printed or typed name of authorized person FOR AUTOMOBILE CLUB Print Form 2604 2 Reset BACKGROUND INQUIRY AUTHORIZATION In connection with licensing appointment consideration by Nation Safe Drivers, I understand that investigative inquiries are to be made on myself as to my credit worthiness. Further, I understand that Deception Control, Inc. acting on behalf of Nation Safe Drivers, will be requesting information from various federal, state, and other agencies which maintain records concerning my past activities, including but not limited to consumer credit report verification. I further understand that these requests may be made at any time during the course of my appointment. I authorize, without reservation, any party/agency contacted by Deception Control, Inc. to furnish the above mentioned information, and I consent to Nation Safe Drivers receiving the above mentioned information from Deception Control, Inc. and/or any of its licensed agents. I further understand that this information will be forwarded to the appropriate regulating entity as required by the licensing entity. Nation Safe Drivers makes no representations or warranty as to the safekeeping of this report at the licensing/ regulating entity. I also release Nation Safe Drivers, Deception Control, Inc. and/or its agents from any claims or liability resulting from the reporting of this background information. I agree that a copy of this authorization release is as valid as the original. STANDARD INFORMATION First: Middle: Last: Other name(s) Used: SSN: / DOB: / Race: / / Sex: Drivers License #: State: Current Address: City: State: Zip: How Long?: State: Zip: How Long?: State: Zip: How Long?: Prior Address (1): City: Prior Address (2): City: YOU MUST PROVIDE YOUR PAST 5 YEARS OF RESIDENCY Applicants Signature:_____________________________________ Date:____________ *PLEASE TYPE OR PRINT LEGIBLY TO ENSURE THE CORRECT INFORMATION IS RECEIVED FROM THE REPORT.