"New Agent's Permit Application - in-State" - Colorado

New Agent's Permit Application - in-State is a legal document that was released by the Colorado Department of Higher Education - a government authority operating within Colorado.

Form Details:

  • Released on February 4, 2018;
  • The latest edition currently provided by the Colorado Department of Higher Education;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Colorado Department of Higher Education.

ADVERTISEMENT
ADVERTISEMENT

Download "New Agent's Permit Application - in-State" - Colorado

451 times
Rate (4.3 / 5) 27 votes
State Use Only
Ck#
_________________
Date_______________
Amount $
____________
Action
_____Approved______Denied
Date_______________
NEW AGENT’S PERMIT APPLICATION - IN-STATE
Agent’s Permit Fee Required
: (See current Fee Schedule) Please note: Agent Permits expire with the school’s Certificate of Approval.
In compliance with C.R.S. 23-64-117, I hereby make application for a license authorizing me to engage in the
business of selling Private Occupational Education Services for the herein named school to the public, and in
support of this application make the following statements under oath:
Name of Person Submitting Application (Existing School Contact):______________________________________
Phone:________________________________
Email:_____________________________________
1.
Agent Name: ______________________________________ Home Phone:________________________
Last
First
MI
Bus. Phone:_________________________
2.
Residence: __________________________________________________________________________
Street
City
State
Zip Code
3.
Employing School: ____________________________________________________________________
Business Address of School: ____________________________________________________________
Street
City
State
Zip Code
___________________________________________
4.
Agent assigned to the following location(s):
5.
Proposed Start Date: _______________________
6.
Date of Birth: ________________________
Place of Birth: ________________________________
MM - DD - YYYY
City
State
7.
Employment History: Submit a complete work history for the last five (5) years, starting with your
most recent position and working back. If more space is needed, attach a separate sheet.
Employer________________________________
Job Title___________________________________
Address_________________________________
From________________ To___________________
Supervisor’s Name_________________________
Phone No.__________________________________
Employer________________________________
Job Title___________________________________
Address_________________________________
From_________________ To__________________
Supervisor’s Name_________________________
Phone No.__________________________________
8.
Mark the appropriate answer below. Have you ever:
a.
Been licensed as a private school agent in Colorado?
Yes__ No__
b.
Been a private occupational school owner before?
Yes__ No__
If “Yes”, complete #1 OR #2 below:
1)
Is it for the employing school listed in this application?
6.a.
Yes___
6.b.
Yes___
OR
2)
Provide name of school(s) and state(s) where located:
6.a.__________________________________________________________________________
6.b.__________________________________________________________________________
In-State Agent’s Permit (Rev. 4/2/2018)
Page 1 of 2
State Use Only
Ck#
_________________
Date_______________
Amount $
____________
Action
_____Approved______Denied
Date_______________
NEW AGENT’S PERMIT APPLICATION - IN-STATE
Agent’s Permit Fee Required
: (See current Fee Schedule) Please note: Agent Permits expire with the school’s Certificate of Approval.
In compliance with C.R.S. 23-64-117, I hereby make application for a license authorizing me to engage in the
business of selling Private Occupational Education Services for the herein named school to the public, and in
support of this application make the following statements under oath:
Name of Person Submitting Application (Existing School Contact):______________________________________
Phone:________________________________
Email:_____________________________________
1.
Agent Name: ______________________________________ Home Phone:________________________
Last
First
MI
Bus. Phone:_________________________
2.
Residence: __________________________________________________________________________
Street
City
State
Zip Code
3.
Employing School: ____________________________________________________________________
Business Address of School: ____________________________________________________________
Street
City
State
Zip Code
___________________________________________
4.
Agent assigned to the following location(s):
5.
Proposed Start Date: _______________________
6.
Date of Birth: ________________________
Place of Birth: ________________________________
MM - DD - YYYY
City
State
7.
Employment History: Submit a complete work history for the last five (5) years, starting with your
most recent position and working back. If more space is needed, attach a separate sheet.
Employer________________________________
Job Title___________________________________
Address_________________________________
From________________ To___________________
Supervisor’s Name_________________________
Phone No.__________________________________
Employer________________________________
Job Title___________________________________
Address_________________________________
From_________________ To__________________
Supervisor’s Name_________________________
Phone No.__________________________________
8.
Mark the appropriate answer below. Have you ever:
a.
Been licensed as a private school agent in Colorado?
Yes__ No__
b.
Been a private occupational school owner before?
Yes__ No__
If “Yes”, complete #1 OR #2 below:
1)
Is it for the employing school listed in this application?
6.a.
Yes___
6.b.
Yes___
OR
2)
Provide name of school(s) and state(s) where located:
6.a.__________________________________________________________________________
6.b.__________________________________________________________________________
In-State Agent’s Permit (Rev. 4/2/2018)
Page 1 of 2
9. Mark the appropriate answer below. If any question below requires a “Yes” answer, attach to this
a written explanation of your answer as well as official documentation.
application
Court
documentation is required for criminal history “yes” answers which details the date of and circumstances
surrounding the case
if applicable
(including,
, charges and disposition of the case which demonstrates completion
of any probation or court ordered terms). (Please note: failure to accurately report criminal history may be grounds for
immediate board action including but not limited to revocation of agent permits or certificate to operate as a private
occupational school.)
Have you ever:
__ Yes__ No
Been convicted of or pled to a felony; or are felony charges pending?
__ Yes__ No
Ever been convicted of or pled to a misdemeanor other than a minor traffic violation; or are
misdemeanor charges pending?
__ Yes__ No
Been dismissed or allowed to resign from any position for immoral or unprofessional conduct?
__
__ Yes__ No
Been licensed as a private occupational school sales agent in any other state?
__ Yes__ No
Been denied, revoked, relinquished or otherwise prevented from obtaining a private occupational
school license in this or any other state?
__ Yes__ No
Been refused bonding by any surety company?
**PLEASE MAKE SURE TO COMPLETE AND NOTARIZE BOTH AFFIDAVITS CONTAINED BELOW **
__________________________________________________________________________
AFFIDAVIT OF APPLICANT
State of________________________
County of______________________, where witnessed.
_______________________________________, being duly sworn, deposes and says that s/he has
(Applicant Printed Name)
received a copy of the Private Occupational Education Act of 1981 and the Rules and
Regulations promulgated pursuant thereto, and has read the Law and the Rules and
Regulations, and further that the above notice has been read, and that each of the statements in this
application and all items attached to this application are true and correct in content to the best of my
knowledge and belief.
_______________________________________
Signature of Applicant
Subscribed and sworn to before me this ______day of ___________________, 20_______.
My commission expires____________________
_______________________________________
Notary Public
__________________________________________________________________________
__
AFFIDAVIT OF SCHOOL
State of________________________
County of______________________, where witnessed.
I, ___________________________________, am the owner or officer of the school by whom the above
(Printed Name)
I certify
named applicant is employed (or is about to be employed) as a private occupational school agent.
that I have provided the applicant with a copy of the Private Occupational Education Act of
1981 and the Rules and Regulations promulgated pursuant thereto.
I further certify that I will
accept the responsibility of actively supervising the applicant during the period the applicant is
in my employ and the requested permit remains in effect. An applicant may not offer or sell any
educational service to any person within the State of Colorado before a license is actually issued to the
applicant.
________________________________________
Signature of Owner or Officer of School
Subscribed and sworn to before me this ______day of ___________________, 20_______.
My commission expires____________________
_______________________________________
Notary Public
In-State Agent’s Permit (Rev. 4/2/2018)
Page 2 of 2
Page of 2