Insurance License Application PhoneThis field is for validation purposes and should be left unchanged.Company Name(Required)Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Name(Required) First Last Title(Required)Phone(Required)Email(Required) Application Year(Required)Payment Method Card Check The fee can be paid online by credit or debit card after processing is complete. Alternatively, checks can be mailed to: City of Roswell 38 Hill Street, Suite 120 Roswell, GA 30075 If you have any questions, please contact Financial Services Division via email or (770) 641-3759.Applicant Consent(Required) I understand that there is a $150 fee per office location and that the fee is due by January 31st annually.Consent(Required) I hereby verify the information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature. (Required)Signature (Full Name)(Required)EmailTo receive a copy of your submission, please fill out your email address below and submit.
