State Form 53175 (R 9-10) Approved by State Board of Accounts, 2010 - in-2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Applicant Information' section. Enter your full name, current address, and contact details clearly.
3. Provide your Social Security Number as required. Remember, this is mandatory for processing your application.
4. In the 'Education Information' section, indicate whether you graduated from high school or obtained a GED. If yes, provide the school name and diploma date.
5. Complete the 'Pre-Licensing Course Information' by attaching a copy of your course completion certificate and entering relevant details about the course.
6. Fill out the 'Certificate of Insurance' section with your insurance provider's information and attach the necessary documentation.
7. Answer questions regarding any previous licenses or certifications accurately. If applicable, provide detailed explanations for any disciplinary actions.
8. Finally, review all sections for accuracy before signing and dating the application affirmation at the end of the form.

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