23 CAR pt. 18, Appendix F. Request For Exemption

ARKANSAS INSURANCE DEPARTMENT APPENDIX F REQUEST FOR EXEMPTION FOR USE WITH 23 CAR pt. 18 TO: ARKANSAS INSURANCE DEPARTMENT Licensing Division 1200 West Third Street Little Rock, AR 72201-1904 Under Arkansas Code §23-64-302(3) and (4) as amended, I held an Arkansas producer license before July 1, 2003, and now am requesting the following exemption(s) Continuing Education Hours: At least sixty (60) years of age. Date of Birth ___________________ . (Attach copy of birth certificate or other document evidencing date of birth.) Have held a license as an agent, broker, producer for a period of fifteen (15) consecutive years. Date first licensed _______________ I certify that the information set out above is true and correct to the best of my knowledge and belief. Signature Name (Print or Type) Arkansas License Number(s) Street Address Telephone Number E-MAIL ADDRESS: City, State, Zip Subscribed and sworn to or affirmed before me a notary public in and for the State of ______________ on this __________ day of _______________ , 20 ___ (Notary seal) Notary Public My Commission expires