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FIXED AGENT APPLICATION FORM
Please complete all required fields!
BUSINESS CONTACT INFORMATION
Business Name
(*)
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Email Address
(*)
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Telephone Number
(*)
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Address
(*)
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How long have you been operating at this address?
(*)
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Type of Business
(*)
Sole Proprietor
Partnership
Corporation
Other
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Business Registration Number
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Number of Locations
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Number of Employees
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Types of services offered
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OWNER DETAILS
First Name
(*)
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Last Name
(*)
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Middle Initial
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Alias
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Date of Birth
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Year
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Telephone
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Email
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Address
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T.R.N
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Number of dependents
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ID Type
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ID Number
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ID Expiry Date
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REFERENCES
Reference#1
Name
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Relation
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Telephone
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Address
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Reference#2
Name
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Relation
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Telephone
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Address
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What service group are you applying for?
First Union Loans
oTuesday Travel
UnionOne Express Online Shopping
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Have you ever used our services:
YES
NO
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Which services have you used?
First Union Loans
oTuesday Travel
UnionOne Express Online Shopping
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Have you or anyone you know ever been employed with us before?
YES
NO
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If YES, when?
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Have you ever been Criminally Charged?
YES
NO
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If YES, explain
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Have you ever filed for Bankruptcy?
YES
NO
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If YES, Please explain with evidence
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If YES, give details
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Do you or any known family member have an active loan with First Union Financial?
YES
NO
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I herby declare that the details furnished above are true and correct to the best of my knowledge. I further understand that any false information provided is in breach of my Agency Agreement with First Union Group and will result in the denial or revocation of being a Fixed Agent for the First Union Group.
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