Application For A Designated Representative License {17A-E}

17A-E - DESIGNATED REPRESENTATIVE LICENSE APPLICATION. Please read the application instructions before you complete the application. Failure to provide the required information may result in the application being considered incomplete. Attach additional sheets of paper, if necessary. The information will be used to determine if you qualify for licensure pursuant to California Business and Professions Code sections 4053. Please provide a written explanation for all affirmative answers. Failure to provide any of the requested information may result in the application being deemed incomplete. Falsification of the information on this application may constitute grounds for denial or revocation of the license. An applicant who fails to complete all the application requirements within 60 days after being notified by the board of deficiencies, may be deemed to have abandoned the application and may be required to file a new application, fee, and meet all the requirements which are in effect at the time of reapplication. www.FormsWorkflow.com