Spirit Dental/Direct Vision Appointment

Applicant Information

First Name

Middle Initial

Last Name

NOTE: If you are using a route or P.O. Box number, please also give the street address. If no street address is available, please give the name of the nearest street.

Home Address

City

State

Zip

Social Security Number

Date of Birth

Gender

Male

Female

NOTE: The Home Phone Number is the one that will be displayed on your Dedicated Enrollment page.

Home Phone Number

Cell Phone Number

Home Fax Number

Email Address

Please only enter a single email address.

Working with GA?

Please enter the General Agency Name.

Were you referred by another agent?

Please enter the name of the agent.

National Producer Number

Don't know your NPN? Click here to search.

Agency Information

Business Name

Business Phone Number

Business Fax Number

Email Address

Please only enter a single email address.

Tax ID #

Business Tax Class

NOTE: If you are using a route or P.O. Box number, please also give the street address. If no street address is available, please give the name of the nearest street.

Business Address

Business City

Business State

Business Zip

Assignment of Commission

How do you want commission to be paid?

Individual

Agency

Assignee Information

Agency Name

TIN#

Tax Class

Address

City

State

Zip

Bank Information (Direct Deposit)

NOTE: Our minimum payout is $10.00 and we pay commissions the 1st business day of every month. For Direct Deposit, the payment will be in your account 48 to 72 hours later, with a statement to be sent via U.S. mail the second working day of each month. For Check payments, the check and statement will be sent via U.S. mail the second working day of each month.

Name on account

Financial Institution

City

State

Zip

Account Type

Checking

Savings

Routing Number

Account Number

Additional Information

Select the states in which you would like to be appointed. Please provide your license numbers for each respective state.

NOTE: If you are licensed and wish to sell in PA or OK, you must be appointed prior to solicitation.

State:

License #:

State:

License #:

State:

License #:

Questionaire

Where do you prefer to receive mail correspondence?

Business

Home

CA, MN, and OK state licensed agents have the right to request a copy of their consumer credit report. Do you wish to receive a copy?

Yes

1. Do you have any pending charges to a misdemeanor or a felony?

Yes

Please explain this:

2. Have you been convicted of or pleaded nolo contendre (no contest) to a misdemeanor or a felony?

Yes

Please explain this:

3. Has any federal or state regulatory agency ever found you to have made a false statement or omission or been dishonest, unfair or unethical?

Yes

Please explain this:

4. Has any federal or state regulatory agency ever found you to have been involved in a violation of federal and/or state regulations or statutes?

Yes

Please explain this:

5. Has any federal or state regulatory agency ever denied, suspended or revoked your registration or license or disciplined you by restricting your activities?

Yes

Please explain this:

6. Has a bonding company denied, paid out on, or revoked a bond for you?

Yes

Please explain this: