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Directors and Officers Form
General Information
Applicant Name
*
Applicant Title
*
Applicant Address (street, city, state, zip)
*
Applicant Contact Name and Title
*
Applicant Contact Phone Number
Applicant Email
WhatsApp Phone Number
*
Telegram Handle
Nature of Operations
NAICS
Year Incorporated
Company Website
Company Type
*
A
Privately Held
B
Publicly Traded
C
Not-For-Profit
D
Financial Institution
Are you working with an insurance broker?
*
Yes
No
Has the Applicant been involved with, negotiated, attempted or transacted any merger, acquisition, asset sale or divestment in the past (18) eighteen months where
such a merger, acquisition, asset sale or divestment involved more than (25%) twenty-five percent of the total assets or securities of the Applicant?
*
A
Yes
B
No
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