Automobile Club Agent Application Renewal {2604}

Form 2604227General Information (Automobile Club Agent Application/Renewal) This form and the information provided are not substitutes for the advice and services of an attorney. Commentary Instructions for Form Preliminary Information: Agent Information: Information Pertaining to Agent222s Moral Character: Submission of this form is consent to conduct a criminal history search of the agent.Execution: Payment and Delivery Instructions:$10 American LegalNet, Inc. www.FormsWorkFlow.com Form 2604 2 This space reserved for office use AUTOMOBILE CLUB AGENT APPLICATION / RENEWAL Form #2604 Rev. 0/201 Submit to: SECRETARY OF STATE Registrations Unit P O Box 13Austin, TX 78711-3 512-475-0775512-475-2815 - Fax New Application Renewal Application Registration Number: Automobile Club Information Name:Agent Information Name:Date of Birth:Address: StreetCityStateZipSocial Security Number: - - Gender: Male FemaleInformation Pertaining to Agent222s Moral CharacterHas Agent ever been convicted of a felony or misdemeanor? Yes No If YES, A.Attach a copy of the court order or final conviction and sentence. Also attach a copy of any paperspertaining 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 CLUBPrinted or typed name of authorized person FOR AUTOMOBILE CLUB American LegalNet, Inc. www.FormsWorkFlow.com