Debit-Check Agent/Agency Authorization FormDebit-Check Agent/Agency Authorization FormBY SIGNING BELOW, I HERBY (PLEASE INITIAL ALL STATEMENTS):Authorize the Company to use My Information for purposes of conducting a commission related debit balance screening, and periodic commission related debit balance screenings as determined in the Company’s sole discretion following the engagement of any employment, appointment, contract, tenure, or other relationship with the Company, utilizing DebitCheck.Authorize the Company to consider the results of the commission related debit balance screening in order to determine my eligibility to be contracted and appointed or determine my eligibility for advancement of commissions as an insurance producer.Authorize and direct Vector One to receive and process My Information as necessary to intentionally disclose and furnish the results of my commission related debt verification screening, whether directly or indirectly, to the Company.Authorize the Company to submit My Information to the Debit-Check service in the event of termination or expiration of my engagement with the Company, whether voluntary or involuntary, to the extent a commission related debit balance is owed to the Company.Authorize and direct Vector One to receive and process My Information and intentionally disclose to any Debit-Check subscriber who submits an inquiry utilizing My Information the results of my commission related debit balance screening, which will contain My Information, to the extent a debit balance is owed.Agent/Agency Printed Name:Signature Sign Here DateFOR COMPANY USE ONLY AGREED AND ACKNOWLEDGED BY COMPANY:Name of CompanySignature Sign Here Name and TitleEnviar al clienteReiniciarSubmit Form
