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This form is for Tend registered agents who wish to be appointed in the State of Florida
Email
*
Licensee First Name
*
Licensee Last Name
*
License Number
*
FEIN/SSN
*
Date of Incorporation/Date of Birth
*
Month
/
Day
/
Year
Program Administrator (Licensed)
Type of Contracts to be marketed by appointed licensee:
Home Warranty (FL 02-51)
Service Warranty Contracts (FL 02-52)
Requestor Name
(if different than Licensee Name)
Submit