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Get Ga Oci Form Gid-103-al 2012

708, West Tower, Atlanta, GA 30334 Phone: 404-656-2101 www.oci.ga.gov 18. Fax: 404-656-0874 Email: agents @oci.ga.gov AGENTS LICENSING GID-103-AL JUL2012 RESIDENT INSURANCE LICENSE APPLICATION Have you ever: A. Had any license, permit, authorization, registration, or privilege denied, refused, revoked, suspended, limited, withdrawn, or restricted . B. Had any other disciplinary action taken against you. YES NO YES NO YES NO YES NO C. Had the renewal of any license, permit, authorization.

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