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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

Privately Held

Publicly Traded

Not-For-Profit

Financial Institution

Are you working with an insurance broker?

Yes

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?

Yes