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Puerto Rico Biographical Affidavit Form

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Puerto Rico Biographical Affidavit Form Page 2
Puerto Rico Biographical Affidavit Form
Office of the Commissioner of Insurance FORM CIS 005 Page 2 of 5
Commonwealth of Puerto Rico
P.O. Box 8330
San Juan, Puerto Rico 00910-8330
10. Memberships in Professional Societies & Associations, you may attach
additional sheets if necessary: __________________________________________
_____________________________________________________________________
_____________________________________________________________________
11. List all employers during the last ten (10) years (Dates, Institutions, Address,
and Titles), you may attach additional sheets if necessary:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
May these employers be contacted ______ If not, which one(s) ___________
_____________________________________________________________________
12. Have you ever been in a position that required a fidelity bond ____________
a. If yes and any claims were made under it, give details: ________________
__________________________________________________________________
b. If yes, have you ever had a fidelity bond denied, cancelled or revoked
__________________________________________________________________
Provide details: ___________________________________________________
__________________________________________________________________
13. List any professional, occupational, and vocational licenses issued by any
public or governmental licensing agency or regulatory authority that you
hold or have held in the past. Specify date of issue, issuer, date terminated
and reason for termination: ___________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
14. During the last ten (10) years, have you ever been refused a professional,
occupational or vocational license or permit or has any such license been
suspended, revoked or subjected to any disciplinary action ______________
If yes, give details: ____________________________________________________
_____________________________________________________________________
Puerto Rico Biographical Affidavit Form