Experienced, Highly Motivated, Wanting to have have Your own Business call or email today.

sales@bandgbrokering.com     770-318-9207

Fill out application and email to sales@bandgbrokering.com   or fax to 866-457-7880

B & G BROKERING, LLC
7140 FREEMAN RD
CUMMING, GA 30028
770-318-9207 PHONE
866-457-7880 FAX




Agent Information Form




Name: ______________________________________ Drivers License # & Issuing State:

______________________________________




Social Security #: ________________________________




Home address: _____________________________________________________ City: _________________________________________




State: _________________ Zip: _________________




Mailing Address (If Different): _________________________________________City: ________________________________________




State: _________________ Zip: _________________




Home Telephone: _______________________________________ Business Telephone: ________________________________________




Fax Number: ___________________________________________ E-mail Address: ___________________________________________




Business References

Give the names of three companies with whom you have done business within the prior year.




Company / Contact Address Telephone Number Years Acquainted




_______________________________________________________________________________________________________________




_______________________________________________________________________________________________________________




_______________________________________________________________________________________________________________




Employment History

List your employment history, starting with the most recent job first.




Employer Address Supervisor Phone# Dates Employed

From:

To:

_____________________________________________________________________________________________

From:

To:

_____________________________________________________________________________________________

From:

To:

_____________________________________________________________________________________________

Authorization

“I certify that the facts contained in this form are true and complete to the best of my knowledge and understand that, if contracted, falsified statements on this form shall be grounds for nullification of contract.

I authorize the references listed above to give B & G BROKERING, LLC. any and all information concerning my previous relationship with them and any pertinent information they may have, personal or otherwise. I also release B & G BROKERING, LLC. from all liability for any damage that may result from utilization of such information.

I understand and agree that no representative of B & G BROKERING, LLC. has any authority to enter into any contract for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized B & G BROKERING, LLC. representative.”







Date: _______________________________________ Signature: _________________________________________________________