State Form 20561 - Notification Of Agent Termination
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1INDIANA COMMISSION ON PROPRIETARY EDUCATION
NOTIFICATION OF AGENT TERMINATION
State Form 20561 (R3 / 9-99)
Fill out the information listed below when an agent(s) is no longer employed at your institution:
Name of institution
Location of institution (number and street, city, state, ZIP code)
AGENT PERMIT
DATE OF
NAME OF AGENT
CARD ENCLOSED
TERMINATION
If the Agent Permit Card(s) cannot be returned for ___________________________________________________________________________________
_________________________________ , provide below a notarized statement certifying this:
WE ARE UNABLE TO RETURN THE AGENT PERMIT CARD(S) FOR THE FOLLOWING REASON:
Signature
Printed name
Official Capacity
SUBSCRIBED AND SWORN TO ME THIS _______________ DAY OF ____________________________________________________, _________ .
Signature of Notary
My Commission expires:
Printed name of Notary
County of residence
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